GP mythbuster 29: Looking after homeless patients in General Practice

When we inspect general practices, we look at how they provide care to different groups of people.

One of these groups is 'people whose circumstances may make them vulnerable'. This includes people who are homeless.

Homeless people face several health inequalities including:

• Significantly reduced life expectancy. The average age of death among homeless people in the UK is 47 for a man and 43 for a woman. This compares to 79.5 for men and 83.1 for women in the general population.
• Greater incidence of long-term physical health conditions. Public Health England estimates that 41% of people classified as rough sleepers have a long-term health condition. This compares to 28% of the general population
• High prevalence of mental health problems. In 2009, the charity Crisis found homeless people were nearly twice as likely to have experienced mental health problems as the general population. Rates of suicide are high among the homeless population.

Homeless people may find it difficult to access healthcare services. Research by Homeless Link shows that 92% of the homeless people they surveyed were registered with a GP. Yet:

• many said they were not receiving the help they needed for their health problems
• 18% had been refused registration to a GP or dentist in the previous 12 months.

Some of these refusals were due to behaviour issues or missed appointments. Others reported they were refused access if they did not have identification or proof of address.

Expected standards of care

GP practices have a responsibility to register people who:

• are homeless
• have no fixed abode
• are legitimately unable to provide documentation living within their catchment area.

Homeless patients are entitled to register with a GP using a temporary address. This may be a friend's address or a day centre. They can also use the practice address to register.

Practices should try to have a way to contact the patient (for example with test results).

Some areas have special services for homeless patients. Practices may refer homeless patients into these in line with local arrangements if:

• it is in the patient’s best interests,
• the patient agrees.

Examples of good practice

When caring for patients who are homeless or are at risk of becoming homeless, you could consider:

• introducing double appointments
• keeping prescriptions as short a duration as possible
• ensuring clear boundaries for consultations are in place
• giving fast access to a named GP
• waiving any charges for housing letters or medical reports

Duty to refer

The Homelessness Reduction Act (2017) came into force in 2018. It places renewed emphasis on homelessness prevention. Section 10 requires public authorities in England to notify a local housing authority (LHA) of service users they think may be homeless or at risk of becoming homeless.

This statutory duty to refer applies to:

• NHS organisations that provide inpatient care
• emergency departments
• urgent treatment centers.

It is not mandatory for primary care providers. However, it is still beneficial for GP practices to refer patients who are homeless, or are at risk of becoming homeless, to a local housing authority for further support.

Referrals must include:

• the service user name
• their contact details and
• an agreed reason for referring the user.

You can refer without consent to safeguard children and vulnerable adults.

Guidance on the duty to refer can be found on Gov.UK.

The Faculty for Homeless and Inclusion

This multi-disciplinary faculty focuses on improving healthcare for homeless and other frequently excluded groups. Its updated standards for commissioners and service providers:

• draw upon the latest evidence of best practice
• provides a framework for commissioning and providing health services for these groups.

Resources for healthcare professionals

• Pathway Homeless Healthcare charity
• British Medical Journal: Streets of Shame: Homelessness and the NHS
• Public Health England: Homelessness: applying All Our Health guidance
• Healthwatch UK: Helping someone who is homeless access healthcare
• Example – healthcare for people excluded from mainstream services
• Example – treating people with kindness, dignity, respect and compassion

Also in GP mythbusters

Information and advice about providing care for vulnerable groups:

• GP mythbuster 36: Registration and treatment of asylum seekers, refugees and other migrants
• GP mythbuster 53: Care of people with a learning disability in GP practices
• GP mythbuster 93: Caring for veterans and their families