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

Health of Homelessness

Homeless people demonstrate worse physical and emotional health status than the general population, including those who reside in areas of high deprivation. Chronic homelessness is characterised by tri-morbidity, meaning they are more likely to suffer from mental ill health, physical ill health and substance misuse, and at the same time less likely to access the health services they need. This leads to rates of mortality in the homeless population that are in high in both absolute and relative terms compared with the general population. [1,2]

People who are sleeping rough, or have slept rough and/or are living in hostels have significantly higher levels of early mortality (especially from suicide and unintentional injuries), physical and mental ill health and substance misuse issues than the general population. High prevalence rates of non-communicable diseases have also been shown alongside evidence of accelerated ageing. Even being homeless for a short period of time increase the risk of long term health issues. [1,3-10]

As mentioned in Victor Adebowale’s second paragraph of his recent BMJ ‘Views and Reviews’ piece [11], the life expectancy difference between the general population and the homeless is stark to say the least. The significant excess mortality rate in homeless people has remained similar during the past 20 years, although shifts in the attributable and related causes of these deaths have occurred, with fewer deaths from HIV infections and more from substance misuse disorders and overdose. [2]

Morbidity levels in the homeless population are higher than the general population, with many homeless people presenting to health services with multiple morbidities and complex healthcare needs. Drug dependence, alcohol dependence and mental ill health are the most frequently reported presentations, especially in rough sleepers and hostel dwellers. [6,10]

Homeless people if not supported, treated effectively and given appropriate access to healthcare services are one of the most costly populations that the NHS provides provision for (8 times that of the housed population), with ‘homelessness’ being a independent risk factor for experiencing emergency department and inpatient admissions high usage status.[7] The lack of access to community-based health care services and lack of appropriate preventive and responsive treatment for homeless people will often lead to increased use of services, especially unscheduled care such as A&E departments and ambulances.[3,4,6,8,12,13] Homeless people not only have higher rates of hospital admissions but also have longer stays (2 days longer for acute admissions) once admitted than the general population. [2]

Homeless people can access mainstream health care provision, but many feel uncomfortable, for a variety of reasons, including that homeless people feel like they negatively ‘stand out’ and often feel they are not treated as equally as the general population in certain health care settings. Some research also suggests that homeless people prefer environments where they know they are welcome.[14,15]

Homeless people experience numerous barriers in accessing healthcare including:

Organisational Barriers

Many homeless people have difficulties in successfully engaging with the bureaucracy and administrative methods of mainstream health services. This can be confounded and create a dual burden by the services then finding it difficult in modifying their bureaucracy to fit the needs of homeless patients. [7,9,12]

Attitudinal Barriers

This again can present as a dual burden to the homeless cohort, as some healthcare professionals can have a hostile or uncompromising attitude towards homeless people or individuals with substance misuse and/or mental health problems. Secondly, many homeless individuals have low levels of self efficacy, with self perceptions of worthlessness leading them not to even approach or access healthcare services in the first place. This is particular prevalent amongst rough sleepers. [7,9,12]

Mental Health Illness and/or Substance Misuse

Experience of mental health and/or substance misuse can significantly hinder decision making and day to day living and can often lead to or exacerbate chaotic lifestyles. [7,12]

[1] Deloitte. (2012). Healthcare for the Homeless. Homelessness is Bad for your Health. London. Deloitte Centre for Health Solutions.
[2] Fazel. J., Geddes. J., and Kushel. M. (2014). The Health of Homeless People in High-Income Countries: Descriptive Epidemiology, Health Consequences, and Clinical and Policy Recommendations. The Lancet. (384). P.1529-1540.
[3] Bephage. G. (2006). Meeting the Healthcare Needs of Older Homeless People. Nursing Times. (102). P.38-41.
[4] Crisis. (2003). Homelessness Factfile.London. Witherbys.
[5] Daiski. I. (2006). Perspectives of Homeless People on their Health and Health Needs Priorities . Journal of Advanced Nursing. (58). P.273-281.
[6] Deloitte. (2012). Healthcare for the Homeless. Homelessness is Bad for your Health. London. Deloitte Centre for Health Solutions.
[7] Faculty for Homeless and Inclusion of Health. (2013). Standards for Commissioners and Service Providers. London. Pathway.
[8] Homeless Link. (2014). The Unhealthy State of Homelessness. Health Audit Results 2014. London. Homeless Link
[9] Lewis, D., Gannann. R., Krishnaratne. S., Ciliska. D., Kouyoumdjian. F. and Hwang. S. (2011). Effectiveness of Interventions to Improve the Health and Housing Status of Homeless People. A Rapid Systematic Review. BMC Public Health. (11). P.1-14.
[10] Wright. N. and Tompkins. C. (2006). How can Health Services Effectively Meet the Health Needs of Homeless People. British Journal of General Practice. (56). P.286-293.
[11] Abedowale, V. (2018). There is no excuse for homelessness in Britain in 2018. BMJ. Views and Reviews.
[12] Crisis. (2012). Homelessness Kills. An Analysis of the Mortality of Homeless People in Early First Twenty First Century England. London. Witherbys.
[13] Martins. D. (2008). Experiences of Homeless People in the Health Care Delivery System: A Descriptive Phenomenological Study. Public Health Nursing. (25). P. 420-430
[14] Fisher. K. and Collins. J. (eds) (1993). Homelessness Health Care and Welfare Provision. OXON: Routledge.
[15] Quilgars, D. and Pleace. N. (2003). Delivering Health Care to Homeless People. An Effectiveness Review. University of York.

Competing interests: No competing interests

26 February 2018
John S Bradley
NHS Principal Public Health Practitioner