People who sleep on the streets for long periods of time have significantly lower life expectancy than the general population (44yrs for men compared to 76yrs for the general population and 42yrs for women compared to 81yrs). They experience severe health inequalities and far poorer health than the general population. Rough sleeping is incredibly dangerous and risky for many reasons; the impact of sleeping outside, exposure to the elements, the challenges of maintaining hygiene & a healthy diet alongside extreme stress, distress and isolation all have a significant impact. People also face higher rates of assault from the public and there are associated risky behaviours, either as a cause or consequence of sleeping on the street, including substance use, alcohol dependence or selling sex to survive, which all seriously impact health and wellbeing.
Across all of our services supporting rough sleeping in the borough, the clients we see are incredibly vulnerable, the majority have reoccurring needs around mental health and substance use and have experienced significant trauma in their lives. These needs can make moving off the street and maintaining accommodation very difficult. They also mean that health isn’t a priority, instead their main worries are about where they will sleep that night or how they will buy their next fix of drugs to avoid sickness from withdrawal. Added to this their mental health may have deteriorated to such a level that seeking help for themselves is no longer possible so services need to be trauma informed and function in a way that completely removes all barriers to access.
Our clients often face exclusion and marginalisation from an early age, many have grown to mistrust authorities and services trying to offer support. Many haven’t accessed health services for years, they can have underlying health conditions they aren’t aware of and are undetected with no treatment. We also have a high percentage of people rough sleeping with uncertain immigration status and no recourse to public funds. Their experience of life in the UK can mean that they have little trust in people and services, they may live underground with little to no contact with mainstream services and unsure of what they are eligible to access - language barriers can make this even more complex.
Traditional health services often just don’t work for people sleeping rough, they may be transient so aren’t registered with a GP and with no fixed address can be refused registration. Their lives can be chaotic so they can’t jump through hoops to access a service, make repeat calls to see a GP or remember to attend an appointment. Our most complex clients find it difficult to access building-based services and support needs to be offered directly on the street.
In Tower Hamlets, we are lucky to have a range of brilliant services supporting the health needs of individuals experiencing rough sleeping – some we commission directly, and others commissioned by the GLA or others. The Rough Sleepers Mental Health Project (RAMHP), provides mental health support and interventions directly on the street, Health E1 Homeless Medical Centre, The Outreach Psychotherapy Team (delivered by Providence Row), the Health Coordinator in the Tower Hamlets Street Outreach team (St Mungo’s) and Groundswell to name a few. We also have fantastic teams making sure people aren’t discharged to the street from hospital – the Pathways Team and Routes2Roots service in the Royal London Hospital. As well as the Reset Team providing interventions around substance use, harm reduction and Needle Exchange. However, there is always more to learn and develop, and the pandemic brought this into sharp focus.
When the pandemic started, keeping people sleeping rough safe and healthy became an immediate concern and we had to think creatively about how we could work with people to provide meaningful support. The ‘Everyone In’ scheme gave us a unique opportunity to do this - when rough sleepers were brought off the streets and into Covid hotels, they were, for a short period of time, together in one place. The low-threshold access to hotels, intensive support offered, national lockdowns as well as fear about the virus was a completely unique situation which meant people came in and stayed in the hotels. This gave us an ideal opportunity to start engaging with people around their health whilst usual barriers were removed.
We wanted to develop an offer that was built around flexibility, by bringing services into hotels and directly to our clients – this included support with GP registration, health checks and support to access medication via the ELFT GP Outreach Team. The Hep C Trust offered Hep C testing and treatment, Positive East offered sexual health screening and advice and the Reset Outreach and Referral team were there day in, day out offering support. And still now, these fantastic services continue to support our remaining hotel in the borough.
As part of this, the GP Care Group gathered some information about the health needs of our clients in the hotels – out of 57 people assessed, a significant number had depression (20%) or other mental health conditions such as Schizophrenia, we also saw high rates of asthma and other respiratory diseases, heart disease, epilepsy and infected leg abscesses amongst other diagnoses.
When the vaccinations became available this created a new challenge; we know people sleeping rough are extremely vulnerable to the virus and that we needed to take a different approach and make vaccinations easily accessible. With support from the Tower Hamlets Public Health team and others, we had agreement early on to offer the vaccine to our clients as a priority. We decided to create a monthly ‘Health Hub’. The idea of the Health Hub is to provide easy access to the vaccine and other health services all in one place, removing as many barriers as possible. We located the Hub at Providence Row, an accessible, friendly space known to the people in the homeless community, many of whom sleep in the immediate area. The staff are trusted and the additional services such as food, showers, and the Advice & Support Team mean that people can be supported holistically during their visit.
The first Hub opened to provide vaccinations in April 2021 and the model has expanded from then. Partnerships have allowed us to increase the impact of the service - as well as having the GP Care Group onsite offering Covid and flu vaccinations, the GP Outreach team provides support with GP registration and health checks, Positive East offer sexual health testing and advice and the onsite Reset team are on hand offering substance use support and a needle Exchange. Hot food is provided and anyone who attends, even to have a chat with one of the nurses, receives a supermarket voucher.
From the outset, we had different expectations for health outcomes, rather than aiming to vaccinate large numbers of people we expected fewer but focused on making every contact count. Every person who comes through the door presents us with the opportunity to start a wider, hopefully ongoing, conversation about their health.
We are incredibly lucky to have a number of wonderful services and partners available and willing to support and we worked collaboratively across the borough to try to encourage people to attend. During each Health Hub, the Tower Hamlets Street Outreach Team are out on shifts throughout the day to support people to attend and offer taxis and practical support to make this easier. They work in partnership with The Outreach Psychotherapy team, Reset Outreach and Referral Team and the Groundswell vaccination peers to increase coverage across the borough. The Groundswell vaccination peers have been fantastic in engaging our clients and offering a different perspective on vaccinations and healthcare. All these services understand the hesitancy around the vaccine and health services for vulnerable people and work to build up trust and relationships to support and encourage people to access services and address their needs. Vaccine hesitancy remains a big challenge and it can take many conversations and attempts to support someone to walk through the door and even have a chat with one of the nurses.
Although we have administered just under 200 vaccine doses through the Health Hubs, the uptake is still very low – only around 20% of our client group in LBTH have received at least one dose of the vaccine. Going forward, we want to continue to offer the vaccine as part of a wider and holistic health offer – as one part of a conversation about someone’s overall health and wellbeing.
The pandemic reminded us how homelessness and health are inextricably linked and how we need to continually adapt our services to support the most vulnerable people in our community. We are now looking forward, using our experience from the pandemic to further develop the Health Hubs and ensure health provision is built into regular service delivery. The next step for us is to take healthcare out to people on the street with a new street-based, physical health service that we are very excited about. We want people to have the opportunity to engage around their health and we understand that healthcare needs to be part of a continual conversation. Although there are always challenges, and the issues are very complex, we are optimistic about the future.