My friend and colleague Aidan Halligan died recently. Like myself he was a Professor of Obstetrics and Gynaecology who then branched out to pursue an eclectic career. We both did a stint in the Civil Service; in Aidan’s case as Deputy Chief Medical Officer. We also shared an interest in the homeless. Aidan established a charity for homeless people (Pathway). The application form for a CLAHRC included a section where applicants were invited to apply for an additional £1 million, and we proposed research into health care for the homeless. Although this supplementary application was unsuccessful, CLAHRC WM continues to pursue a research project in this field and we are delighted to be collaborating with Pathway.
The homeless are quite a hard client group to define precisely. Perhaps, rather than trying to narrow down the definition, it is more useful to broaden it out. The concept can be expanded to include many who occupy the margins of society, irrespective of whether they are homeless in the literal sense – they will include many people recently incarcerated, those with severe drug abuse, and nomadic populations. The difficulties they encounter overlap with those of economic migrants and asylum seekers, although their psychological assets are different – descending to the bottom is not the same as starting there. I suspect that in many instances facilities are closed to migrants, while they are open to the ‘homeless’ – just not accessed.
The homeless have it rough, even when they are not asleep – their mortality rate is not just 1.4 or 1.7 as for many medical conditions such as diabetes, but many times greater than other people.   The life expectancy of a homeless person in a high-income country is probably worse than that of a person of similar age living in a Nairobi slum.
But homelessness is not common – it is not a ‘public health problem’ in the sense of diabetes, depression, dementia, cancer, and so on. However, the homeless occupy the extreme left end of the inequalities distribution and, as hinted earlier, their personal ‘assets’ are low. ‘Tough love’ may be good in many circumstances, but not for the homeless. It is not always easy to imagine the plight of another human, and when the person is unclean and aggressive the well of compassion can dry up. But, as suggested in a previous post, it is up to us whether we let it stay dry or replenish it. Aidan had the imagination to at least glimpse what it might be like at the ‘extreme left’ and so replenished his well. So, yes, we should be prepared to pay more per unit of health gain for homeless people. How much more is for society to decide according to a collective ‘social welfare function’.
But good intentions are not enough. Interventions for people who are homeless have been published recently. Co-ordinating social and different types of medical care is key to improved health and wellbeing for the homeless, as it is for other groups of people with complex needs (acute medical illness, multi-morbidity). This can be achieved with different combinations of case-management, critical time interventions, and assertive outreach. It also appears to be the case that getting the person into a permanent dwelling is critically important and improves access to, and effectiveness of, other services – hence the ‘housing first’ concept. Such services need to permit alcohol, while trying to address the problem, else the person will end up back on the street. Of course, those who don’t drink also don’t want to share dwellings with those who do. I never said this was going to be easy!
What is CLAHRC WM going to do about it then? Inspired by Toby Lewis, Chief Executive of Sandwell and City Hospital in Birmingham, we plan an intervention targeted on the A&E department. Emergency care is the sharp-end of homeless care and a case picked up here and managed across specialities and across the hospital/community interface could add real value. No more patients discharged onto the street in dressing gown and slippers. At least, that is our hypothesis. Our nascent plan is to pilot the intervention at Sandwell and City hospital and then, if it appears successful, roll it out – yes under a step wedge evaluation! We are not solipsistic, but seek collaborators at home and abroad.
Aidan Halligan was speaking to an orthopaedic surgeon who had done a brilliant knee operation on a homeless person. When Aidan asked how the patient had managed back in the community, the surgeon was unable to give an answer. “You are a good surgeon,” Aidan said, “But when you help homeless people, not just their knees, you will be a great surgeon.”
— Richard Lilford, CLAHRC WM Director
- Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario. JAMA. 2000; 283(16):2152-7.
- Barrow SM, Herman DB, Córdova P, Struening EL. Mortality among homeless shelter residents in New York City. Am J Pub Health. 1999;89(4):529-34.
- Hibbs JR, Benner L, Klugman L, et al. Mortality in a cohort of homeless adults in Philadelphia. N Engl J Med. 1994; 331(5):304-9.
- Hwang SW & Burns T. Health interventions for people who are homeless. 2014. 384:1541-7.
- Hemming K, Haines TP, Chilton PJ, Girling AJ, Lilford RJ. The stepped wedge cluster randomised trial: rationale, design, analysis, and reporting. BMJ. 2015;350:h391.