Hospitals must do more to break the cycle of homeless ill health and re-admissions

Tuesday, 10 February 2015 - 11:12am

Hospital admission is an opportunity to engage people not only in their immediate care but also to offer broader support. How can we ensure this is done effectively? 

Photograph: Thirteen of Club (Flickr)
Photograph: Thirteen of Club (Flickr)

In 2007, Paul Wilson was discharged from hospital back onto the street after a knee operation. In terrible pain, he was left to fend for himself with nothing but a pair of crutches and a bag of morphine.

Almost a decade later, within minutes of visiting The Strand to conduct research on unsafe discharge for homeless people, Paul found that little had changed and that people were still struggling with very similar experiences to his. Stigma and discrimination towards homeless people continues to prevent them getting the care and support they need. 

When it comes to the NHS, homeless people are often last in line for admission and treatment and first out the door for discharge. The question is, given their often complex and ongoing health concerns, why does this practice continue?

With his direct experience, Paul has been advising Healthwatch England’s Special Inquiry into unsafe discharge, which involves listening to people’s experiences - and much of that experience has been difficult to hear.

When we asked one person what would have made their stay in hospital better they replied that they just wanted to be asked “how are you feeling?”. They added: “As soon as they know you are homeless you are worth nothing.”

Street homelessness poses a particular challenge to the health service. Discharge back to the streets with a persistent health problem can quickly lead to readmission and then a revolving door in and out of hospital as ongoing care needed to recover is not provided.

Joseph, who was readmitted five times with the same problem, told us: “I wasn’t given any information or support and I was discharged back to the streets. I would have liked more joined up help with care and housing.”

Some staff in the NHS are prepared to bend the rules in order to give homeless patients more time or ensure that they receive follow-up.

One local Healthwatch told us about a district nurse who broke into a man’s temporary flat after she felt he was discharged early. She found him shivering and unable to breathe – she suspects he would have died had she not intervened.

The efforts of this nurse are to be commended, yet are a further example of a system that is unable to facilitate effective healthcare for patients experiencing homelessness.

This example also highlights how this problem is not only confined to those who are sent back to the streets. Street homelessness accounts for a tiny fraction of the homeless population. We must also take into account those staying in temporary housing accommodation, bedding down in hostels or staying on a friend’s sofa.

Hospital admission is an opportunity to engage people not only in their immediate care but also an opportunity to offer broader support. If staff ask the right questions about where people will stay after leaving hospital they can point them in the direction of support to help resolve housing issues.

The frustration is that these issues are fixable and, if they stop the cycle of readmission, would save money in the longer term.

Part of the solution lies in changing attitudes of frontline staff towards people experiencing homelessness. While we heard of many staff who were compassionate and caring, others appeared to being making harsh judgements and lacking in the human kindness we all expect when we are unwell. Involving people in planning for when they leave hospital means they feel empowered and better able to look after themselves in the longer term.

It cannot be left to health services alone to tackle this issue. Housing is the biggest issue facing homeless people when they are discharged, so only an approach that involves health, social care and housing services will ensure that the needs of homeless patients are met during and after treatment.

By addressing problems in this way, we can stop vulnerable individuals slipping through the gaps in the system and ensure they are receiving the ongoing care and support they need.

Evaluation of the Homeless Hospital Discharge Fund

Homeless Link's evaluation of the £10m Department of Health Homeless Hospital Discharge Fund. 


Why invest in improved hospital discharge process?

Homeless people are heavy users of acute health services and many are stuck in a damaging cycle of poor health and hospital re-admission. This briefing exaplains how getting the admission and discharge process right improves people’s health and saves money. 


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Dr Katherine Rake

Chief Executive, Healthwatch England

Dr Katherine Rake OBE is Chief Executive of Healthwatch England, the independent consumer champion for health and social care in England. 

Twitter: @katherinerake