What do you call a postcode lottery for health care when you have no postcode?

Tuesday, 24 January 2017

Head of Community Engagement Warren Finney explores homelessness and end-of-life care.

When we reach the cold winter months it’s only natural that we spare a thought for the difficulties faced by people who are less fortunate than us. For me, I start to think about people who are homeless – with food in short supply and cold, wet nights spent on hard, damp floors where it’s too cold to sleep.  

Prior to working in the hospice and health sector, I worked in the social housing and homelessness sectors. In that time, I helped organisations to create services and provide support that would help homeless people – making an impact on someone who would otherwise be faced with a life of rough sleeping.

We’re coming up to the 50th anniversary of the creation of Shelter – the campaign charity for people who are homeless, which came into existence following the 1966 film Cathy Come Home. The film dramatised the fall of a young couple into poverty and subsequently homelessness. One Christmas, I received a copy of Cathy Come Home; given my career focus at the time I think the person who bought it for me felt I would appreciate it – and, in truth, I did. It was a stark reminder of how easy it is for anyone to fall into a situation where they lose their job and, as debts begin to pile up, their home and then, before they know it, end up living on the street.

I spent many years working in support services with people who were or had been homeless. My thoughts were often on how we might immediately assist them and if we could build a longer-term relationship with them – linking them to support from a local GP or health service, and helping them find a place to live and a job. I wasn’t naive: I knew that, in many instances, the homeless people I was working with had life-limiting conditions, but, end-of life care support and services were not seen as the priority at the time.

Is homelessness on the rise?

Accurately counting the numbers of people who are sleeping rough is notoriously difficult – homeless people don’t tend to stay in one place for long which makes it hard to calculate an accurate figure. However, according to figures published in February 2016, 3,569 people are estimated to be sleeping rough across England on any one night. 

Unfortunately, the trend is growing. From 2014 to 2015, rough sleeping instances have increased by 30%, and it’s estimated that rough sleeping has increased by 102% since 2010. Across England, the biggest percentage increase in rough sleeping was in the South West. These figures suggest that the situation will only have got worse since then.

Shelter suggests that the number of people sleeping rough or living in temporary accommodation (such as a hostel/B&B) has hit almost 255,000. That’s significantly more than the population of Swindon.

People who are homeless are often invisible. I doubt many people would take the time to think about how a homeless person could die 30 years before an ‘average’ person might expect to. It’s unlikely, too, that people would think about how a homeless person could be in terrible pain due to a serious or life-limiting illness, but can’t access the medication we and our loved ones would expect to, simply because of where they live or, more accurately, where they don’t live.

Evidence suggests that rough sleepers find it particularly difficult to engage with health and social care services for a number of reasons, including having no fixed abode, chaotic lifestyles and addiction issues which directly affect their health. The result of all of this? The long term homeless have an average life expectancy of just 47 years.[1]

The press often report that you might get access to certain drugs or treatments if you live in a particular area – the so-called ‘postcode lottery’. But what happens if you have no postcode at all? How do you access the care and support you need to live well and, ultimately, die well? For homeless people it can be extremely difficult to access even the most basic health care, let alone specialist end-of-life care and support.

How can Prospect Hospice help?

We began thinking about the role we could play in supporting people who are homeless and who have a life-limiting illness.

We contacted organisations that work locally to help people who are homeless and, unsurprisingly, they confirmed that the lack of end-of life care was a serious issue. We recognised that we could help through our education services so, through some great joint working and funding from Health Education South West, we developed a training programme to help frontline staff working with homeless people. The programme aims to equip staff with skills in understanding the issues faced by people who are dying and to teach them how to have the often difficult conversations about what people want at the end of their lives and where they might want to die. We also teach staff how to have a conversation with the person they’re supporting around making contact with long-lost family or friends, and perhaps how they could reach out to offer forgiveness or mend relationships while they still have time.

We know this training won’t instantly solve the problem. We know we need to do more – and we intend to. We’ll be working with local providers to find the best ways in which we can help frontline staff and those who are homeless and have a life-limiting illness.

We also know we’re not the only organisation now engaged in this work; nationally, there are many other hospices and care and support agencies who are doing similar projects. There are also conversations taking place at a national level, which are trying to bring a greater understanding of the wider issues and support needed, as well as some cohesion to the support that is already out there.

Clearly, excellent end-of-life care is just one of the urgent needs someone who is homeless might have. A roof over their heads, support to deal with physical and emotional trauma, training and support to rebuild their life, as well as understanding from everyone in society – not just in the winter, but all year round.

Everyone in society has a role to play in supporting the most vulnerable people, not just health and social care agencies. Time is of the essence for people living on the street, particularly for those who have a terminal or life-limiting illness. Despite our current focus, we can’t act fast enough. However, I suspect, collectively, we could all act faster – the question is, will we?


[1] Homelessness – A Silent Killer, Crisis, 2011