Caring for the homeless in their own environment could prevent deaths

Primary health care service outreach (PHSO) interventions, where patients are attended to in their own environment, could be key to improving health in the homeless population, finds a new UCL study.

The life expectancy of people experiencing homelessness in the U.K. is currently 30 years shorter than that of the general population, and previous research has shown that a quarter of these deaths could have been prevented if a doctor had been seen in time.

There are multiple barriers for the homeless population to accessing primary health care, from having to provide proof of address at registration, to the rigidity of appointments, stigma, and the GPs’ lack of awareness of their complex health care and social needs. Therefore, many of the homeless population wait for their health to deteriorate to the point of needing emergency medical care at A&E before seeking help.

For the new systematic scoping review, published in Family Practice, a multi-disciplinary team of UCL researchers analyzed 24 studies, which considered the impact of PHSO on homeless populations in high-income countries between 2006 and 2020.

PHSO may include GP community outreach, special health centers near homeless populations and mobile clinical teams in hostels. In the U.K., PHSO is managed by local primary care services, general practice, community pharmacy, dental, and optometry (eye health) services.

The research team led by Valeriya Kopanitsa (UCL Medical School) and supervised by Diana Margot Rosenthal (UCL GOS Institute of Child Health, UCL Collaborative Center for Inclusion Health) found that PHSO addressed barriers to accessing health care, through being situated in convenient locations and organizing flexible appointments, fostering a good doctor-patient relationship and being co-located with other services that provide basic necessities. As a result, PHSO was often the main source of health care for the homeless population.

Researchers also suggest that PHSO could lead to improved continuity of care at decreased costs to the NHS—as the services could employ volunteers and health care students, invest in equipment, and run the service over a longer period of time.

Lead author, Valeriya Kopanitsa, said, “PHSO evidently have the potential to mitigate some of the barriers to accessing health care services experienced by the homeless population, thereby improving continuity of care.

“Our research suggests that PHSO should be part of an integrated care system of combined specialized and mainstream primary care services with supportive peer workers rather than a standalone parallel service. Cross-sector collaboration with community bodies (e.g., shelters, hostels and charities) is vital in addition to the co-location of services such as housing assistance and food banks already accessed by some of the most vulnerable HPs.

“PHSO could also run at decreased costs to the NHS—as the services could employ volunteers, health care students and experts with lived experience, invest in equipment and run the service over a longer period of time.”

The study still identified, however, that certain categories of the homeless population, such as young people, rough sleepers, people with severe illness and mental illness were more likely to be neglected, even in outreach care.

To build on this review, comparative studies over a longer time period could be performed to compare the outcomes and efficiency of primary healthcare outreach for the homeless population with mainstream primary healthcare.

Study limitations

A formal critical appraisal was not performed to identify the quality of the selected studies, and the reviewed studies did not have control or comparison groups to compare their intervention groups against.