Initiatives to wrestle with the health consequences of homelessness are deprived of a coherent national strategy, say campaigners. Mark Gould hears the growing calls for the NHS to take the lead
The life expectancy of people in England is now in the late 70s for men and early 80s for women. Unless, that is, you are homeless. A homeless person in England has an average life expectancy of just over 40, according to shocking research by the homeless charity St Mungo's.
"It's the sort of life span you would have had in the Middle Ages," says the charity's director of programmes Peter Cockersell.
Amid the freezing temperatures of early 2009, St Mungo's opened two emergency shelters, concerned by reports of rising cases of frostbite among its clients.
Mr Cockersell describes the level of healthcare provision for those without a permanent address as a "postcode-less lottery".
"There are some good services but not enough have got all the elements together," he says.
Providing healthcare for homeless people is a conundrum. Often those in most need are so unwell they refuse to accept help. Where homeless people are hospitalised, St Mungo's says they report high levels of hostility or indifference from staff and are more likely to discharge themselves too early, often because they cannot cope without alcohol.
But there is a growing clamour for the NHS to take the lead in providing specialist services for the homeless because of the massive burden they place on "normal" services.
Last year, a reinvigorated government strategy promised to eradicate rough sleeping by the start of the 2012 Olympics. But Gill Perkins, head of communications for Homeless Link, the umbrella group representing organisations working with homeless people, says: "The Department of Health hasn't really come to the table properly. We would look to it for overall strategy in terms of healthcare for the homeless. After all, the eradicating rough sleeping strategy talks about all departments coming together."
However, Ms Perkins pays tribute to Places of Change, the£70m Department for Communities and Local Government initiative that has improved the environment and services in hostels and day centres.
The number of officially homeless people has been declining. Figures released in December show 14,340 "households" (not the same as individuals) were accepted as homeless by local authorities in England in July to September 2008 - a 13 per cent reduction compared with the same quarter last year and 60 per cent down on 2003 figures. The statistics also show a continuing reduction in the number of households in temporary accommodation: down to 72,130 - a 29 per cent drop from 2004 levels.
Some areas have also seen reductions in rough sleepers. Last November, a count in Reading recorded zero rough sleepers.
But elsewhere there has been a sharp rise. In London an increase has occurred at least since December 2007, when official returns from London boroughs showed 1,892 people were "verified rough sleepers". By last September the figure had jumped to 2,226, up 17 per cent.
Mr Cockersell says it is estimated that around 3,000 people, including many Eastern European economic migrants, slept rough as they passed through London last year. And charities are expecting to see more people on the streets as the financial crisis deepens and unemployment and house repossessions bite.
St Mungo's report Homelessness: it makes you sick, released in November, revealed that 40 per cent of homeless people had a diagnosed mental health problem but the true level is likely to be more like 70 per cent if those who have not been diagnosed are included. More than 80 per cent of those surveyed had a health problem. Almost a third of this group were receiving no treatment at all for any of their health issues.
"Some people have the lot: mental illness, addiction, physical problems plus homelessness. Around 10 per cent were in care as children so you have people with a history of chronic disenfranchisement," says Mr Cockersell.
He adds that despite the numbers of homeless people with mental health problems or a personality disorder who self-medicate with drugs or alcohol, many mental health and personality disorder services will not take on clients who misuse drugs or alcohol.
Showing the way
Services can be designed for homeless people. When a new client arrives at a St Mungo's hostel, they get a full health and social needs assessment within 14 days. The GP service at its central London hostel is provided by the out of hours service for Camden and Islington PCT. This can throw up multiple needs.
"Some people have so many conditions they need to be seen by eight or 10 specialties. That is challenging for anybody, so if you are a homeless person who finds it difficult to express yourself or finds doctors' surgeries strange and alienating it's even harder," says Mr Cockersell.
St Mungo's clients say they want a full package of primary healthcare, with a doctor, practice nurse, foot care and counselling. In response, the charity wants to set up an intermediate care centre with 24-hour medical cover, as a step up from a normal primary care service but a step down from hospital, to cater for the specific needs of homeless people.
A pilot project backed by Lambeth primary care trust for Lambeth residents opened in mid-January. It may sow the seeds for a London-wide scheme.
"We need the co-operation of a PCT but the problem is that PCTs are aligned to their own patch and don't take to the idea of using money and resources on a pan-London service," says Mr Cockersell. He adds that an intermediate care service would cut unnecessary ambulance call-outs and attendances to accident and emergency by people with no other access to health services.
Former deputy chief medical officer Aidan Halligan, now director of education at University College London Hospitals foundation trust, agrees. His own research reveals accident and emergency attendance for homeless people is six times the local average, while their admission rates are four times higher, length of stay is twice as long and overall costs are six times the average.
Last year the trust's charitable trustees approved a bid by Professor Halligan to train homeless people as "care navigators", to identify vulnerable people, "hold their hands" and point them to the appropriate service.
He hopes to create a hybrid hostel-style scheme in accident and emergency to care for the homeless. This would be complemented by a step up "hospital within a hostel" - like the intermediate care unit envisaged by St Mungo's.
Professor Halligan says: "It's beyond belief that the average age of death of a homeless person is 40.2. The NHS does fantastic work but it doesn't provide universal coverage for the homeless."
Elsewhere in London, Westminster PCT's homeless healthcare team was set up in 2002 in recognition of the fact that Westminster has the highest proportion of rough sleepers in the UK. It sees 1,500-2,000 people a year. Some are seen once but there are many regulars, including a core group of men and a few women in their 70s and have lived on the streets for many years.
Westminster clinical manager Alison Danks agrees the needs of the homeless are so complex that they need specialist services.
"Even though they may be entitled to accommodation they refuse. Some 60 per cent of clients have mental health issues so there is a debate as to whether [refusal] is really down to personal choice," says Ms Danks.
The Westminster service is seen as one of the best in the business.
Ms Danks says this is because it brings services to places where homeless people feel comfortable, namely day centres. It provides nurse-run surgeries at St Martin in the Fields church in Trafalgar Square - itself home to a homeless charity, Connection at St Martin's - and at the Passage day centre in Victoria and a centre in Marylebone.
"If when you turn up at a GP surgery you get a shirty receptionist and it happens one or two times you don't go back. Day centres are where you have all the services in one place," says Ms Danks. "People may come in for a meal or shower and you can ask whether they want to see the nurse or doctor. You may be able to say 'you aren't looking too well' to them. It's about building things up.
"Sometimes it's one step forward and three back - you have to be philosophical."
White cider - the curse of the streets
"It's 7.5 per cent alcohol and it's never seen an apple in its life. You can buy a two litre flagon for under£2 and that would knock most people out. It should be banned," says Health Xchange community nurse and alcohol worker Jackie Conarty.
Strong white cider is cheap because it is taxed at a much lower rate than other alcoholic drinks. Ms Conarty believes the drinks industry cannot justify creating a drink whose sole market is addicts.
"We did liver toxicity tests on people who drank white ciders and people who drank beers like Tennents Super, which is strong, but is basically malt, water and hops. White ciders are just chemicals. The liver functions were worse in those who drank white ciders."
The Portman Group, which represents the drinks industry, said it has upheld a range of complaints about the way white ciders are advertised. Recent decisions include a ruling that naming a 7.5 per cent strength cider Blackout was irresponsible as it encouraged reckless drinking. It also ordered the makers of another 7.5 per cent white cider, Mega White, to remove the words "mega strength" from its packaging and add responsible drinking warnings.
COPING BUT CONSTANTLY BUSY: BIRMINGHAM'S HEALTH XCHANGE CENTRE
Just around the corner from the shoppers of the Bullring in Birmingham, a few men are queuing outside Health Xchange, a primary care centre for the homeless run by Heart of Birmingham primary care trust and based in the William Booth Centre, a 75-bed Salvation Army hostel.
Among them is David (not his real name). Aged 43, he is a tall, thin man who uses a walking stick. He says he has been an alcoholic since he was 14. At one time he was drinking 11 litres of strong white cider and a bottle of vodka a day. He is now living in a nearby hostel but explains that years of rough sleeping, alcoholism and intravenous drug addiction have exacted a horrific price on his health.
"I've got osteoporosis and osteomyelitis - that's infection of the bone marrow. I had bones in my jaw taken away because of infection and I have leg ulcers that must be dressed. I can't eat solids so I have to get Ensure (a food supplement drink) as well," he says.
David has come to Health Xchange for many years.
"I used to be called the Scarlet Pimpernel, because I wouldn't turn up for appointments." Now he says that with the help of alcohol workers he is cutting down his drinking. "I am down to one litre of cider a day."
John is 43 but he looks 20 years older. His face is reddened and weather beaten. It is his first time at Health Xchange. He wants help to stop drinking.
"I came to get help. I'm coughing up blood and I weigh nine stone when I should be 11 stone," he says.
The William Booth Centre is warm, clean and welcoming. But it has the elusive, slightly queasy smell - part super strength cleaning agents, part human - that evokes institutional care.
Health Xchange covers the whole of Birmingham and sees clients who are rough sleepers or in bed and breakfasts or hostels. Rent books, bills or other proof of identity are not needed.
A full health service is offered but as it opens for office hours only, after 5pm the alternative is accident and emergency or the walk-in centre in a city centre branch of Boots.
Jackie Conarty, a community nurse and alcohol worker at the centre, glances at colleagues as she struggles to come up with the right words for how Health Xchange is doing.
"Coping? Probably. We are constantly busy."
Her colleague Sue disagrees. "There is so much more that could be done," she says.
Ms Conarty warms to the subject. "We are all nurses but we are like social workers as well. It's very intense and takes time. Accommodation and benefits all impact on health and you can be on the phone for an hour trying to sort it out."
Ms Conarty says she and her colleagues also do outreach work on the streets and as a result have to be tough.
"We are pretty tolerant of people coming in with drink but we do tell people we won't tolerate bad behaviour. We get a lot of effing and blinding but the bad language used is largely an expression of anger with the world."
Primary care nurse Clare Cassidy says one concern, given the massive problem of alcohol addiction, is that it still takes too long to get referrals to detoxification services.
A local inpatient detox centre closed last year and is not expected to reopen for some time. So some service users will have to wait many months to get a full package to help ensure recovery.
Meanwhile, the charity Vision Care for Homeless People offers a free eye screening and spectacle dispensing service at the centre. Volunteers include dispensing optician Sarah Baylaya and optometrist Sandhya Gosai, who both ordinarily work for Boots but are at the centre every Monday.
Today they have referred one man to hospital as he has a sliver of metal in his eye. Another needs a specialised contact lens that actually keeps his eyeball in shape.
Both Ms Baylaya and Ms Gosai say it is rewarding to do the simple things that enrich lives - like getting someone fitted with reading glasses.
Common health problems among homeless people
Drug and alcohol addiction
Mental health issues
Skin complaints, including lice and scabies
Foot problems such as trench foot and fungal disorders
Less common are tuberculosis, hepatitis, HIV and sexually transmitted infections