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RCGP Safeguarding toolkit

Part 2C: Identifying adult abuse and neglect

Safeguarding those who are homeless

“Homelessness is devastating, dangerous and isolating.”

—Crisis

Those who experience homelessness are members of our communities who have high levels of need but also experience marked barriers to services and the support they need, including health services.

Homeless people have significantly lower life expectancy. According to the Census 2021 data, the average age of death of a homeless man is 45 years. The average age of death of a homeless woman was 43 years.

People sleeping on the street are almost 17 times more likely to have been victims of violence. More than one in three people sleeping rough have been deliberately hit or kicked or experienced some other form of violence whilst homeless.

Homeless people are over nine times more likely to take their own life than the general population.

Findings from an audit carried out by Homeless Link found that:

  • people experiencing homelessness suffer worse physical and mental health than the general population
  • 63% of respondents reported they had a long-term illness, disability, or infirmity
  • there is a substantial increase in the number of people with a mental health diagnosis – 82%
  • 45% respondents reported they are self-medicating with drugs or alcohol to help them cope with their mental health
  • there are significant barriers to healthcare and that people experiencing homelessness are over reliant on emergency health care services
  • for those who had been admitted to hospital, 24% had been discharged to the streets
  • nutrition presents a big challenge – a third of respondents reported they only eat one meal/day on average.
Types of homelessness:
  • Rough sleeping: this is the most visible form of homelessness.
  • In temporary accommodation: this includes night/winter shelters, hostels, B&Bs, women’s refuges, private and social housing.
  • Hidden homelessness such as staying with family or friends, sofa surfing or living in unsuitable housing such as squats or in ‘beds in sheds’ situations.
  • Statutory homelessness: families or individuals who are accepted as being owed support by their local council because they are likely to become homeless or are homeless.
Multiple exclusion homelessness

Definition:

“People who have been ‘homeless’ (including experience of temporary/unsuitable accommodation as well as sleeping rough) and have also experienced one or more of the following additional domains of deep social exclusion – ‘institutional care’ (prison, local authority care, psychiatric hospitals or wards); ‘substance misuse’ (drug problems, alcohol problems, abuse of solvents, glue or gas); or participation in ‘street culture activities’ (begging, street drinking, ‘survival’ shoplifting or sex work).”

Multiple Exclusion Homelessness. A Safeguarding Toolkit for Practitioners.

Adults experiencing multiple exclusion homelessness face:

  • significant increased risk of serious abuse, exploitation and neglect
  • an escalation of their health and care needs
  • a reduction to their life expectancy.

They also have hidden vulnerabilities which include:

  • problems stemming from childhood trauma
  • acquired brain injuries
  • chronic mental and physical ill-health
  • limited mobility
  • severe addiction: “individuals experiencing multiple exclusion homelessness are in a life threatening double bind, driven addictively to avoid suffering through ways that only deepen their suffering.” (Adult safeguarding and homelessness: experience informed practice by Local Government Association).

Many people who are at risk of, or who are experiencing, long term homelessness have been exposed to trauma. Trauma is prevalent in the narrative of many people’s pathways to homelessness. Research has shown that people who are homeless are likely to have experienced some form of trauma, often in childhood. 85% of those in touch with the criminal justice system, substance misuse and homelessness services have experienced trauma as children.

People who are homeless are vulnerable to all types of abuse. The safeguarding issues surrounding them are often highly complex and can include experience of abuse and trauma as a child and an adult, ongoing vulnerability to abuse, exposure to violence and high risk of death from treatable medical causes, violence, suicide, and/or drug overdoses. Where someone may present a risk of harm to others this has to be carefully managed. Some may also be parents and therefore safeguarding of children must always be taken into consideration.

Safeguarding people experiencing homelessness

Safeguarding people experiencing homelessness should follow the same principles as safeguarding any adult which are set out in section 3 of this toolkit: Responding to abuse and neglect. Additional risks and needs of this population also need to be taken into account which are set out in Homeless Link Safeguarding Adults at Risk guidance.

Interpersonal and personal:

  • Mental health needs.
  • Dependence on alcohol and/or drugs.
  • Brain damage.
  • Lack of purposeful activity.
  • Odd, anti-social or embarrassing behaviour.
  • Difficulty in communicating.
  • Impact of trauma and adverse experiences.
  • Poverty.

External:

  • Staff working in isolation.
  • Unconscious bias, stereotyping and prejudice.
  • Community disengagement, fear and resentment.
  • Lack of access to safe and adequate housing.
  • Lack of access to wrap-around support to address health and social care needs.
  • Victim of gatekeeping and inflexible policies.
GP Registration

A particular barrier to healthcare for people experiencing homelessness can be difficulty registering with a GP. This however should not be the case. EVERYONE in England, Northern Ireland, Scotland and Wales is eligible to register with a GP and receive primary care services free of charge. Homeless patients are entitled to register with a GP using a temporary address, which may be a friend’s address or a day centre. The practice address may also be used to register them which can mean letters about appointments, for example, can be sent on proactively or opportunistically.

Relevant guidance on patient registration is available here:

Doctors of the World also have a helpful briefing on GP registration:

“Refugee and migrant communities, people experiencing homelessness, and Gypsy Roma and Traveller communities, have low levels of GP registration and are often incorrectly prevented from registering with a GP surgery. Everyone in England, Scotland, and Wales is eligible to register with a GP and receive primary care services free of charge, regardless of immigration status. This is because immigration status is not relevant for primary care, and anyone can register and use primary care services. Some surgeries may ask to provide documents, such as proof of address, proof of identity or proof of immigration status, or an NHS number in order to register, but they should not refuse to register if these can’t be provided. If individuals can’t provide these documents, they should say that they don’t have these documents but that they do live within the practice boundary and would like to register with the GP as a patient.” 

Doctors of the World also have a Safe Surgeries Toolkit to support GP practice staff in ensuring everyone in their community can access the healthcare they need. 

References