The homeless are a group of people I have a particular passion to try and support. It may be that, being ex-military, I’ve come across a few of my brothers on the streets, or it could be that I can empathise with rough sleepers as I also know how bloomin’ cold it is to sleep under the stars in mid-winter – even though mine was a dalliance of a few days… not a month, year or even decade(s) of living outside.

For the purpose of this blog, when I use the term ‘homeless’, I’m referring to those who live on the streets – i.e., rough sleepers – rather than that other unfortunate group who have no home, the so-called ‘sofa-surfers’.

At any time, there are many thousands of people who live rough on our streets. Annually, there’s a ‘rough sleeping snapshot’ undertaken, and the last count took place in 2019 when 69% of England’s local authorities took part. Whilst only an estimate, on a given single night in the autumn of 2019, there were 4,266 people sleeping rough in our communities.

This is only a simple snapshot and quite often these figures are considered to be vastly under-calculated. This information is ordinarily released annually in February, so, should a snapshot have been completed in 2020, I have concerns that there may be a significant increase as a result of financial hardships and domestic violence due to the pandemic.

The homeless are more vulnerable right now. On top of the problems of not having a place to call home, the biting cold (it was announced that it was the coldest January in a decade), managing physical and mental illness, poor diet, potential drug and alcohol addiction, comorbidities and of course the pandemic, life on the streets must be pretty awful just now.

Whilst this is nothing that isn’t already known, over the past few weeks there has been a growing campaign for the homeless to be included in one of the priority groups to receive a COVID vaccine.

Whilst I’m not saying that any one group of individuals should queue-jump at the expense of another, we of course do need to be acutely aware that the homeless often have a lifestyle that goes hand in hand with numerous ongoing chronic issues and, significantly, a reduced life expectancy of both 41% and 49% – or just 47 years for a man and 43 years for a woman.

As such, should they not already be in one of the categories deemed most at risk?

Circumstantial lottery of life

 My son is a school teacher, so let it be known that I’m not teacher-bashing here (especially as he’ll be influential in the choice of my future care home), but I do have a small itch that needs scratching… Practically every morning, I listen to a rant from one breakfast news presenter or another who trumpets the importance of getting our teachers vaccinated, an argument that would seem to have been fuelled by their vocal unions.

Of course, I do have some empathy here; teachers do have an additional risk and it’s really important to look out for our younger generation who, frankly, must be completely bewildered right now. But why only teachers?

Surely this group isn’t exposed to more daily risk than any other group of essential workers, e.g. those working in a supermarket? Especially as supermarket workers aren’t able to work from home. But surely neither of these two groups trump the needs and risks encountered by the homeless. I’d argue strongly that whilst some occupational groups merit looking into, neither of these two will be sleeping outside tonight in minus whatever.

Good news is inbound!

Last month, some PCNs and local councils agreed to start vaccinating their homeless groups. Oldham Council in particular made national news as being the trailblazer. Local GP and Councillor, Dr Zahid Chauhan, provided this interesting argument to gain the needed approval to commence vaccinating; he suggested that:

“Over 70s and care home residents were prioritised for the vaccine, we reminded council that the physical frailty of a rough sleeper was something closer to 90 [years]”.

Following this, they attended the local shelter where 30 homeless people were vaccinated.

The following post on Practice Index’s Forum highlighted that Oldham aren’t alone and other areas have also started to vaccinate their homeless. Pulse has reported the same, and Caroline Lucas (MP for Brighton Pavilion) also raised this very question to Matt Hancock, asking when the DHSC plans to both identify and reach out to the homeless group, which will enable them to be vaccinated.

Great news, as this has now prompted Nadhim Zahawi to respond.

Practices’ obligations

As you’re probably aware, there’s already a requirement to support the homeless within primary care; specifically, CQC Nigel Surgery No 29 insists that we look after this group due to their health inequalities.

Therefore, we do need to consider the homeless as we would any other vulnerable group. As such, I’d suggest that Dr Chauhan in Oldham gives a very strong argument.

Furthermore, within the above link, it states that:

“…homeless people may find it difficult to access healthcare services and that whilst 92% of those homeless people who were surveyed were registered with a GP, many said they were not receiving the help they needed for their health problems and surprisingly 18% had been refused registration to a GP or dentist in the previous 12 months.”

Why is this so?

Please see the New Patient Registration Health Check Policy [PLUS] as this details the reasons to decline any patient application and it should be noted that not having a fixed address is not a reason to disbar, even if they don’t have any form of identity.

The following extract from the policy surrounding ID checks states:

“Should any patient not possess any form of identity; we must be equally non-discriminatory in our approach to any prospective patients as this may affect the registration of certain groups within the community… Therefore, the organisation should not routinely expect a patient to present photographic proof of identity as this could be considered to be discriminatory.”

New NHS England and NHS Improvement Initiative

Armed with links, stats and a new promise from the ‘centre’, I’ve spoken to Practice Index’s source at NHS England and NHS Improvement about these concerns and what forthcoming initiatives can be expected.

I’ve received the following exclusive:

Everyone in England is entitled to register with a GP. Many people who experience health inequalities can face barriers when trying to register. Practices should not turn people away because they do not have proof of ID, address or immigration status. People can also register if they do not know or do not have an NHS number.

Being registered with a GP has many benefits, the most important one at the moment is that GPs can identify those people who are clinically vulnerable to COVID-19 and ensure that they are invited to get a vaccination.

We want to support all people, particularly those in inclusion health groups to register with GPs. We want to work together with colleagues working in the voluntary community and social enterprise sector to ensure that this message comes from people trusted in/by these communities.

Please help us by using the resources below to support the people you are working with to register with a GP.

Access card

In partnership with a number of organisations, NHS England and NHS Improvement are soon to be “distributing ‘access cards’, both physical and digital, which support the message that everyone is entitled to register with a GP. On the back of the card is the NHS England and NHS Improvement Customer Contact Centre number, for people to use if they have been refused registration”.

Voluntary, Community and Social Enterprise (VCSE) organisations will get physical copies of the access card from their local Healthwatch which they can share with the communities they work with. This card will also be available electronically.

To further support this release, NHS England and NHS Improvement will also soon be releasing a social-media campaign and posters welcoming the homeless to register if they have not done so.

Action by practices

NHS England and NHS Improvement have advised that:

“GP practices are also being asked to review their websites to include a statement that you can register without ID/address and to offer an initial health assessment for new registrants to identify vulnerability to COVID”.

So, good news, as not only will this hopefully stop future refusals for the homeless person, this sounds like it’s the springboard needed to obtain an earlier-than-planned COVID vaccine. Furthermore, in support of all this, it sounds as if this will also support practice actions to manage their CQC obligations.

But, in the meantime, whilst we wait for this new initiative, the moral question is:

Tonight, outside it’s going to feel like -4°c; there’s snow all across northern England, so should primary care wait for this direction from NHS England and NHS Improvement, or do PCNs simply take the ‘bull by the horns’ and agree to commence vaccinating our homeless sooner?

Further support

There’s lots of information out there, and I’ve given links to only some of the more prominent sources.

Specific advice to support homelessness during COVID-19 can be sought from www.gov.uk and, of course, as already mentioned, please have a look at the Nigel Surgery link.

Charities:

• Shelter provides general information on homelessness, information for rough sleepers and access to healthcare and accommodation during COVID
• homeless.org.uk
• bigissue.com
• crisis.org.uk
• citizensadvice.org.uk