Patients on the margins
Author: Amanda Lyons
GPs can play a vital role as carers and advocates for some of Australia’s most vulnerable citizens – people who are homeless.
If it seems as though the issue of homelessness has become more visible in recent years, this perception is likely correct. One in 85 people across Australia accessed a specialist homelessness agency in 2015–16,1 with the number of those who utilised these services increasing in almost every state and territory since 2011.
While people who are homeless are often the subject of concern and even fear among wider society – as evidenced by the early-2017 situation in the Melbourne CBD in which ‘rough sleepers’ in front of Flinders Street Station were forcibly removed by police following concerns expressed by members of the public and local businesses – they are also some of its most vulnerable members.
‘It is understandable that people are worried about the way homelessness presents and the perceived threat to safety, but [the public] often don’t appreciate the complexity of causative factors,’ Dr Gracie Vivian, a GP with the Fremantle-based mobile medical service for homeless patients, Freo Street Doctor, told Good Practice.
‘Clearing the streets of homeless people does not solve homelessness; rather, it exacerbates it. It will displace people to other areas and cause them to feel more shunned and disengaged from society at large, without even touching upon the deeper issues.’
For those who have never experienced it, it can be difficult to understand what homelessness is like or how people find themselves in that situation.
‘It may sound obvious, but it’s easy to forget that people don’t just wind up on the streets for no reason at all,’ Dr Vivian said.
According to Dr Edmund Poliness, a GP at the Living Room, a Melbourne-based primary health service for homeless people, the factors involved people becoming homeless are complex and multifactorial.
‘Most people become homeless not because of a single issue, but because of the “Swiss cheese” model of crisis, of multiple things all going wrong at the same time,’ he told Good Practice.
The story of each person experiencing homelessness is unique, although there are often similar patterns of disadvantage and adversity.
‘Sometimes an acute crisis has precipitated the situation. For example, domestic violence or a relationship split,’ Dr Vivian said.
‘At other times, the patient’s circumstances appear to unravel slowly; deteriorating social bonds leaving individuals without support when times get tough; unemployment; difficulty reintegrating into society when leaving jail; and, very commonly, chronic mental illness and alcohol and drug problems.
‘These reasons seem to fall into categories of physical and/or mental vulnerability, compounded by social isolation, which makes obtaining and sustaining secure accommodation very difficult.’
Barriers to care
Although people who are homeless tend to have substantially higher rates of illness than the broader population, they often lack access to effective healthcare services.2
‘For example, if you’re hungry and cold and haven’t got anywhere to sleep, you’re going to deal with those things first, not health issues,’ Dr Andrew Davies, a GP and director of Homeless Healthcare, Perth’s largest provider of health services to homeless people, told Good Practice.
People who are homeless may also live with depression, which can prevent them from feeling motivated to seek healthcare.3 Additionally, the stigma that surrounds homelessness can make them unwilling to present in a traditional healthcare setting.2 One way to address this latter problem is to take the treatment to the patients, which is the method practised by Freo Street Doctor.
‘[Our patients] feel welcomed, understood and not judged by our homeless-specific GP services,’ Dr Vivian said. ‘Furthermore, our services are accessible, physically in terms of being set up in central metropolitan or suburban community centres with the vans set up in a simple, non-ostentatious way; and financially, as our service is free.’
Another way to provide accessible healthcare for people who are homeless is to establish clinics in places such as community drop-in centres, a method used by the Living Room and Homeless Healthcare.
‘Doing that overcomes some of the barriers that homeless people have in coming in to see a GP,’ Dr Davies said. ‘By going to the drop-in centre, where people are fed and warm, you actually have a chance of getting them to see a doctor.’
Ensuring the accessibility of services in these ways can also help GPs build a relationship with a patient population that can be mistrustful of doctors and healthcare institutions in general.
‘A lot of patients reiterate the fact they “don’t like to see doctors”,’ Dr Vivian said. ‘This makes me mindful that building trust and rapport and creating a positive health experience is essential to ensure these patients are more likely to connect with the medical system again, and hopefully become more empowered to value and care for their own health in the future.’
People who are homeless often tend to experience the same physical health problems as most other patients, but in greater severity.
‘Everything is two to six times more common than in the general population, so you get more of it,’ Dr Davies said.
Dr Poliness recommends taking a broad approach to the healthcare of these patients.
‘They need good healthcare that’s not only preventive, but considers them in a bio-psycho-social-spiritual way and individualises to their needs,’ he said.
‘It’s generally bread-and-butter medicine and tends to present quite late, so diagnosis is not that difficult. But then it’s more about coordinating a plan about how we’re going to treat this, and what we’re going to do about it.’
For many homeless patients, however, these bread-and-butter health problems are also accompanied by a range of more complex issues.
‘The standard patient for us has what we call “trimorbidities” – as well as mental health and drug and alcohol problems, they have physical health problems,’ Dr Davies said. ‘About two-thirds of the patients have drug and alcohol issues, about two-thirds mental health, and about half of them have at least one chronic physical problem.’
Because of these multiple needs, a multidisciplinary team approach is often effective for homeless patients.
‘The model we use [at the Living Room] is based around having a doctor, a nurse and various other allied health staff members,’ Dr Poliness said.
‘The podiatrist we work with is amazing – for a lot of homeless people, being able to get around on healthy feet is very important. We’ve also got a mental health nurse, a psychologist and a dual disability worker.’
When working in drop-in centres and fixed-site clinics, which encourage repeat visits by homeless patients, Dr Davies believes the best approach is to not take on too much in one consultation.
‘You don’t have to solve everything at the first go,’ he said. ‘If you try and deal with every problem and spend an hour and a half with homeless patients, they will likely quickly get tired of you. So being a good GP is chipping away at problems.’
With mobile services like Freo Street Doctor, on the other hand, patients tend to present for acute problems in more of an ad-hoc fashion. This makes it important for the healthcare team to make the most of patient presentations.
‘Our GPs and nurses are vigilant at using every encounter as an opportunity for screening for chronic disease, building rapport and providing advice about preventive health, as we’re not sure if we may see the patient again,’ Dr Vivian said.
‘Sometimes consultations may unexpectedly run on for some time, because we cover as much as we can.’
The underlying issue
The problems that can make people vulnerable to homelessness also extend beyond physical issues and mental health.
‘You’re more at risk if you’ve got poor social determinants of health,’ Dr Poliness said. ‘That includes poor literacy and poor ability to fill out forms properly, especially when financial pressures come up.
‘If you’ve got poor literacy or ability to re-finance or organise things, or explain to Centrelink why you’re under these circumstances, they’re the situations where you’re more likely to fall into homelessness.’
These same issues also make it difficult for people to find their way out of homelessness once they have fallen into it, and homelessness has a huge impact on a person’s health.2 It is for this reason that Dr Davies believes it is vital for practitioners to, where possible, attempt to get directly to the heart of the matter when treating homeless patients.
‘Unless you deal with the underlying problem – the fact people are homeless – you don’t actually make a significant improvement in their health,’ he said.
The desire to tackle the problem at its source is what drove Dr Davies to launch Homeless Healthcare.
‘In late 2007 I started looking at some of the models for GP services for homeless people. I struggled because I wanted to do something different, but had no money to do it,’ he said. ‘Then I thought, “If I got all the right equipment and stuck it in the back of my car, then I could just go to a drop-in centre and set up there”.
‘The other big advantage was working closely with the homelessness services that are trying to re-house people.’
The approach of prioritising patients’ state of homelessness as an immediate problem involves having members in the healthcare team who can help patients take care of practical matters in addition to physical and mental health issues.
According to Dr Poliness, the Living Room’s community development workers, some of whom have experienced homelessness themselves, are vitally important to providing high-quality holistic care.
‘They do a lot of the practical things, like helping fill out forms, or re-engaging with Centrelink or other services,’ he said. ‘They know which services have funding for temporary housing or from which you can access a swag if you are sleeping rough on the street, or if you can engage patients with other people who have been previously homeless and now the patient is allowed to sleep on their couch, or share a house.’
In a further effort to house people who are living rough, Homeless Healthcare is part of a collaborative campaign among homelessness services called ‘50 Lives, 50 Homes’, which is trying a new approach to re-housing.
This approach involves removing the barriers that are encountered in a stepped approach. Rather than being placed in transitional accommodation with other troubled residents and required to meet strict behavioural standards before they can move on, people who are homeless are given their own space right away, as well as the support they need to cope.
‘“50 Lives, 50 Homes” has got much better success rates at one and two years than the transitional accommodation system,’ Dr Davies said.
Dr Vivian emphasised the importance of remembering that every homeless person is exactly that, a person, and has their own unique story.
‘When I reflect on the stories of the homeless patients I’ve been lucky enough to encounter, I am reminded when I see homeless people, be it professionally or just by chance as I walk around town, that each person has a story that has brought them to this point and that there’s more to the human than meets the eye,’ she said.
Dr Poliness believes GPs can have a key role in helping homeless patients.
‘We should be advocates for our patients who are homeless,’ he said. ‘They are someone who has an issue, like any other patient.’
Dr Poliness has found through his own work that, although providing care to people who are homeless can be challenging, it can also be extremely rewarding.
‘I find it to be great,’ he said. ‘I see patients I’ve seen over the past eight years who are no longer homeless. They often greet me and want to tell me the stories of how things have gone for them, improvements they’ve made in their lives and how things have changed.’
- Australian Institute of Health and Welfare. Specialist homelessness services 2015–16. Canberra: AIHW, 2016. Available at www.aihw.gov.au/homelessness/specialist-homelessness-services-2015-16 [Accessed 18 May 2017].
- Turnbull J, Muckle W, Masters C. Homelessness and health. CMAJ 2007;177(9):1065–66.
- Research Alliance for Canadian Homelessness, Housing and Health. Housing vulnerability and health: Canada’s hidden emergency. Toronto: Reach3; 2010.