Keeping homeless patients off the streets
BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i318 (Published 19 January 2016) Cite this as: BMJ 2016;352:i318
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One way to obtain an idea of how many people are homeless is to walk about in a town centre and count those who are sleeping on the street. Statistics have been recorded since the Second World War, a night in 1949 revealing a total of 5 persons on the streets of London. In 2013 the count was 2,400, bloated by a third when compared with only 2010. Halfway into the 2010s about 6,500 persons can be found “sleeping rough” in the capital.
It cannot be overlooked that they are almost all men. Women, as a rule, are not reduced to the same fate. Women cope, men fall apart. One gender is evidently better at self-preservation than the other. Why are these men sleeping on the streets? Why do they crowd on a day in winter for a soup-kitchen to drive into the midst of Birmingham? Examined by doctors, each life is a wreckage, and bespeaks mental illness, broken relationships, a migrant’s plight, drug and alcohol abuse, a discharge from the fortressed front of prisons and mental health units. Bradford in the North of England, a city which falls into the conurbation of Leeds, has migrants from Eastern Europe holed up in dilapidated factories.
The buildings are litter-strewn, full of plastic cutlery, soiled carpets, everted umbrellas, dry lavatories, oblongs of smashed windows. Rats and pigeons meander on hills of detritus. In summer or winter the temperature inside is the same as that outside. But a roof is still preferable to the pavement. Retailers have, after all, fitted iron spikes in their shopfronts to prevent any overnight slumberings. A third of those sleeping on the streets of London are bleary-eyed rovers from Poland, Romania, Bulgaria, Hungary and the Baltics. Others, with less misfortune, live congestedly by the dozen in ramshackle houses. Providers of cheap labour, the migrants are exploited, paid as little as £50 a week for a cartload of work for which a Briton asks ten times as much.
The number of persons without a home has risen with arithmetical zest over the decade since 2006. Governmental data concur with the figures of the charities, but such tabulations are believed, as always, to be a partial picture. As they forage for a meal, the ones on the street are a mere puddle in a lagoon. Street-sleepers were a jot beside the total of 112,000 who told their local councils in 2013 that they were homeless. The 112,000 represented an expansion by a quarter since 2009. Universities such as York and Heriot-Watt have academics who have interestedly spied on the trends of the 2010s. The causes of homelessness they say are, chiefly, the unaffordability of housing and a shrinkage of the welfare state (“benefit cuts” after the 2005-2010 downturn).
A comparison with stretches of postwar history is informative. Such retrospection finds that the lot of the homeless was televised starkly in 1966. Aired by the British Broadcasting Corporation, the drama “Cathy Come Home” had a sizeable effect on viewers. It induced a twinge of realisation : charities for the roofless–– Crisis, Shelter and Centrepoint––were founded in the late 1960s as a response. A decade later, the rights of a homeless person were concretised in the Housing Act of 1977. The 1980s and 1990s were an era in which families could buy their council-owned houses, and attain security. And the mid-2010s has hordes who are sans roof in the prevailing demographic.
Next to the televisuals and cinematics is the sapience in the books. Presenting the author as not only an artist, an escapist, an entertainer, but as a chronicler of the past who breathes in the present, are the nonfictions of George Orwell. A monolith of British literature, his “The Road to Wigan Pier” (1937) has an entire disquisition on the matter of housing shortage.
Born in India, Orwell by orientation was a southerner. From the writers of the last century, he is thus separable from the northern Englishmen, like John Braine of Bradford and Anthony Burgess of Manchester, literates who were acutely aware of their northernness in a society run by the Hooray Henrys from The South. By propensity not a fictionist, but a journalist and an intellectual, Orwell was au courant with the hardships of the proletariat. A social gradient exists in every town, but he wanted to see the vertical gradient in a longitudinal country. Bearing his southern sensibilities, he trundled to The North.
Standards of living are higher than Orwell’s day, but the issue of housing, with a larger share of the young renting than a decade ago, is patently as fulminant in the 2010s as it was in the 1930s :
‘Housing shortage’ is a phrase that has been bandied about pretty freely since the war, but it means very little to anyone with an income of more than £10 a week, or even £5 a week for that matter........... But in the industrial areas the mere difficulty of getting hold of a house is one of the worst aggravations of poverty.
I am told that it is bad form for a writer to quote his own reviews, but I want here to contradict a reviewer in the Manchester Guardian who says apropos of one of my books :
Set down in Wigan or Whitechapel Mr Orwell would still exercise an unerring power of closing his vision to all that is good in order to proceed with his wholehearted vilification of humanity.
Wrong. Mr Orwell was ‘set down’ in Wigan for quite a while and it did not inspire him with any wish to vilify humanity. He liked Wigan very much–the people, not the scenery. Indeed, he has only one fault to find with it, and that is in respect of the celebrated Wigan Pier, which he had set his heart on seeing. Alas! Wigan Pier had been demolished, and even the spot where it used to stand is no longer certain.
––from the classic nonfiction “The Road to Wigan Pier” (1937) by George Orwell
Competing interests: No competing interests
During busy twilight shifts in A&E, I have came across young people who are adamant that they would not return home to their parents, preferring rather to present themselves as ‘homeless’ to a local shelter.
A home is not just bricks and mortar.
A home is made up of the group of people who consider each other family. Therefore, I believe that homelessness is the loss of meaningful social relationships, such as those that exist between family members.
Family breakdown leads to a significant proportion of homelessness (1).
Data collection by Homeless Link (2) in 2014 showed that 64% of youth homelessness was due to relationship breakdown and loss of accommodation with family or friends.
In an ideal world, family should promote mental and physical well-being and provide a safe, protected environment in which to grow and thrive. When this environment is compromised, family ties can suffer to such an extent that the young people, for whatever reasons, no longer see the ‘home' as a viable living option.
What they then face whilst sleeping rough on the streets continues to chip away at them, increasing vulnerability to mental and physical illnesses. Substance misuse, theft, violence and prostitution are just some of the problems they encounter. These ‘social evils’ are destructive to their mental and physical health, often leading to mal-adaptive coping mechanisms (3), such as drug and alcohol abuse, thus completing the "trimorbidity" (7).
In some cases, charities and social services can, by providing accommodation and other services, help the homeless individuals towards rebuilding their lives(4). In other cases - and all too often - these interventions are not enough to break free from the vicious cycle young homeless people can find themselves in. This leads to long term homelessness which then leads to the increasing use of acute health services and lengthy admissions.
I believe that there is a substantial need for early intervention in order to prevent loss of the family unit and alienation of young people. By creating a more accessible service, incorporating reconciliation or respite for families, issues can be tackled much sooner to prevent setting off the chain of events triggered when a person feels there is nowhere for them to go.
(1) http://www.insidehousing.co.uk/family-breakdown-to-blame-for-youth-homel...
(2) http://www.homeless.org.uk/sites/default/files/site-attachments/201411%2...
(3) http://www.centrepoint.org.uk/about-us/the-issue/why-young-people-become...
(4) http://www.crisis.org.uk/data/files/publications/Exec%20summary.pdf
(5) http://poverty.org.uk/81/index.shtml
(6) http://www.homeless.org.uk/facts/homelessness-in-numbers/statutory-homel...
(7) BMJ 2012;345:e5999
Competing interests: No competing interests
A. Gulland’s article shines a light on the reality of providing the homeless with medical care and also hones in on two basic problems (1).
The first is the complete lack of a scheme that plays anything like a significant role in these patient’s lives and in fact, the article acknowledges that improvised initiatives with only short-term funding are as good as it gets.
The situation is one shared by other countries, Italy included, where the only time any action is taken is when there is some sort of climatic emergency that needs managing, in other words, excessive cold in the winter or excessive heat in the summer.
The second is the obvious lack of a personalised modus operandi by attending doctors who usually adopt the same diagnostic-therapeutic approach that they would take with patients who have a home and a family network to support them.
The first problem exposes the extent to which our socio-health services have, over recent decades, moved away from the welfare model put forward by Beveridge in the 1940s (2). The needs and well-being of the individual lay at the heart of that model, including and especially those individuals who have experienced hardship and whose future prospects seem unlikely to improve. Providing such people with the best assistance possible does, at the very least, benefit the rest of the community in that there is less likelihood of any diseases or conditions spreading and any anti-social behaviour can be contained.
Common sense says that a patient who is provided with the best treatment available for an acute alcoholic episode and is then sent back onto the streets with no support plan in place, one that would minimise the probability of otherwise inevitable relapses, is doomed to failure despite all efforts made to help him in the first place.
One possible solution to the problem might only require the strategy currently adopted to manage it to be tweaked. Rather than basing treatment according to a merely compassionate logic, perhaps there should be a clearer, unambiguous integration of the operational ambit of the social and health sectors that goes beyond that of help centres where the only assistance provided and expected is a bed for the night – and perhaps a hot meal. The shelters that take in mothers in need with children may provide a better model as they have qualified staff on site or on call who ensure a support plan is drawn up aimed at helping vulnerable and fragile people regain their independence and dignity.
The second problem shows how far the medical profession has ended up straying, in recent times, by a business-like mindset aimed at providing performances. When the gravity of a medical problem experienced by different people is the same, it is social determinants that create a disparity in the treatment they receive and that is something the doctor cannot ignore.
That does not mean, obviously, that the vulnerable should be deprived of the diagnostic-therapeutic services that the rest of the community are guaranteed. On the contrary, it is because services for those who are socially vulnerable need to be effective that a multi-disciplinary approach to any project must involve social workers if it is to be about more than treating. Caring must be a part of curing too.
References
1. Gulland A. Keeping homeless patients off the streets. BMJ 2016;352:i318;
2. Beveridge W. Social Insurance and Allied Services. 1942.
Competing interests: No competing interests
What is Home?
Home is hope, but no home is nope: no address, access, ingress, egress, or recess. Just endless, friendless aloneness. To quote Wordsworth, "And homeless near a thousand homes I stood. And near a thousand tables pined and wanted food."
Competing interests: No competing interests