Two-thirds of GP practices from a sample of 100 in London declined to register a patient without an address, contrary to national rules which are meant to ensure homeless and excluded people can get healthcare, HSJ has found.

NHS England guidance states anyone can register with a GP without proof of address, and that people without a permanent address “can still register using a temporary address or the address of the GP surgery”.

Practices normally need to record an address, but the exception rule is meant to ensure people who are homeless, or living in unstable or short-term accommodation, are still able to access primary care or referrals for secondary services.

Despite this, when HSJ called 100 randomly selected practices in London (about 9 per cent of the total), 64 refused to register the caller.

The “mystery shopper” told receptionists at each GP that they did not have a permanent address but were living temporarily in the local area, and would not be able to provide an address. If declined registration, the caller informed the call handler of the NHS England guidance and advice, giving them a further opportunity for them to agree or check with colleagues.

The reasons for refusal varied, with many practices stating their computer system could not process registrations without an address. One receptionist said they “could get in trouble for registering someone outside of their catchment area”.

Another stated that although in theory, the GP did accept homeless patients, they would have to be “categorised as homeless by the council” before being registered, a process that the receptionist would not advise the caller about.

Of the 36 practices which agreed to register the caller, 12 said they would do so by registering the caller under the practice’s address.

We focused on London because of its high homeless population.

Asked by HSJ about the finding, GP leaders did not defend the practices.

Instead, Royal College of GPs chair Professor Kamila Hawthorne said: “It’s vital that homeless people are able to easily access any healthcare and services they need, particularly given the health risks posed, for example, by rough sleeping.

“While lack of ID or proof of a fixed address can make it difficult to send appointments by mail, or to visit a patient should a home consultation be required, it should not be a barrier to a patient registering at a GP practice – or to access necessary health interventions. I have worked in practices where we have found ways to overcome these issues.

“Patients who are homeless are some of our most vulnerable in society, whether they are, for example, rough sleeping or parents with young children who are forced to rely on temporary accommodation due to a lack of social housing. It is critical that homeless patients, whatever their circumstances, receive joined-up support from health and social care professionals.”

British Medical Association England GP committee acting chair Kieran Sharrock said: “It is vital that people who are homeless are empowered to register with a GP so they can get the care they need. This may sometimes mean using a temporary address, such as a friend’s or a day centre, and under certain circumstances, the practice address may also be used to register someone. Practices should not put barriers in the way, for instance there is no requirement for proof of identity or address.”

‘Children turned away’

Homeless health experts told HSJ our findings reflected many people’s experiences.

Stan Burridge, who was homeless for years after leaving the care system, is now director of Expert Focus, which advises services on improving access for people who have experienced homelessness.

He said being turned away from a GP “has happened to most homeless people at one point or another”, and was “the most blatant discrimination”.

“GPs are supposed to accept everyone, but when there’s nothing to back the guidance up, they won’t,” he said.

Homelessness healthcare nurse Kirit Sehmbi told HSJ the barriers were “ridiculous”, and says they exist for even the most vulnerable patients. “I’ve seen GP surgeries turn children away,” she claimed.

Rough deal: the inequalities faced by the homeless

Rough sleepers face some of the worst health outcomes in the population, with studies showing they are 10 times more likely to suffer premature death. GP Kate Pitt said: “We’re talking about an average age of death in the 40s. We also see incredibly high levels of early onset frailty; research in London hostels showed that people in their 50s had frailty equivalent to 80 year olds”.

Being unable to access a GP can be devastating for rough sleepers. Dr Pitt, who works in a clinic specifically for people experiencing homelessness, says she “often sees chronic conditions that can be managed well with good primary care, but without that they have progressed to an advanced stage where there would have been the opportunity for someone to intervene earlier”.

With homelessness rising in the UK, the issue is affecting more people than ever before. Outreach nurse Jane (not her real name) said: “With the cost of living crisis, we’re seeing even more people asking for help, saying they can’t afford rent. It’s not the same client group we’re used to seeing.”

She says it’s not just administrative barriers blocking rough sleepers from essential healthcare. “There’s a lot of discrimination, often through non-verbal communication. When I’m helping the patient engage with another healthcare professional I can tell already that they’ve read my patient’s history. If they know the patient has a history of addiction, I might ask: ‘Would you give my client a few paracetamol?’, and they’ll give them hostile look.”

Jane said more enforcement was needed, as the NHS guidance “does need to be something that is absolute law”, while “clinicians need to receive more education on the client group, too”.

Isobel Mckenna, area manager at London-based homelessness charity Thames Reach, said: “Often, the very first response you get on reception is a rejection. It’s the first hurdle. It shouldn’t be allowed, but it does still happen”, she said.

“It’s also really difficult for someone with significant mental health issues to interact with GPs like you or I might.

“Mental health issues can make calling at 8am to get a same day appointment, sitting in a busy waiting area, and explaining the presenting problem far more challenging.”

Mental illness is at far higher rates among those sleeping rough. Research suggests 12.7 per cent of people experiencing homelessness have a psychotic illness, 11.4 per cent are depressed and 23.1 per cent have a personality disorder.

Because of the gaps, there are specialist services for homeless patients in several areas, although these themselves are often facing funding problems.

And Mr Burridge said: “Specialist services are needed right now. Do I think they should be funded as a long-term solution? Absolutely not.

“That lets healthcare services off the hook, when really the same healthcare services should be given to everyone. Even if you’re smelly, addicted, mentally ill – if you’re living in the gutter you should be able to get healthcare. Homeless people are people too.

“I’m the director of my own company and I’m able to contribute to society. I wouldn’t be able to do that if my healthcare hadn’t been sorted out. Outcomes will remain poor as long as we allow discrimination to remain unchecked.”

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