Homeless people urgently need timely and effective healthcare

Study shows it is often too late when homeless people present with cancer at hospital

• Signs of treatable conditions may be confused with effects of harmful lifestyles
• Cancer is second-largest cause of death among homeless people admitted to hospital in England
• Screening and early detection and intervention seen as key

Nearly one third of homeless people in England die from treatable conditions, researchers say.

In a study that highlights the urgent need for more timely and effective healthcare for this patient group, researchers from University College London examined data on 3,882 individual homeless hospital admissions that were linked to 600 deaths in the three years to November 2016.

One fifth of the 600 deaths were caused by cancer, and the disease was identified as the second-largest underlying cause of death among homeless people admitted to hospital.

Life-shortening health consequences

‘Homelessness has catastrophic, life-shortening health consequences, the causes of which are preventable and largely treatable,’ says nurse consultant and study co-author Alistair Story.

• RELATED: Why emergency nurses have a vital role in care of the homeless

‘Nurses can play a major role in addressing the extreme health inequalities experienced by homeless people, not least by ensuring that they can access screening for cancer and other conditions where early detection and intervention is key.’

Kendra Schneller, a nurse practitioner at Guy’s and St Thomas’ NHS Foundation Trust in London, agrees with the study’s findings, saying:  ‘I have never met a homeless client who has been diagnosed with cancer at a stage where something could be done. They are always near the end of life.’

Ms Schneller works for a nurse-led community outreach service in the trust – called the health inclusion team – that visits people in hostels, shelters and refuges.

‘A lot of people I meet who have cancer don’t know they have it until they have symptoms at the end stages. Often it is liver cancers, but there are other cancers as well. Then we will refer them onto the two-week wait, but it is difficult to get our clients to engage once they have been diagnosed. Often it is too late for recovery once they present to us.’

Signs to look out for

Forging closer links between her team and cancer nurses would help to increase opportunities for earlier detection, says Ms Schneller.

‘Cancer nurse specialists need to be more aware of the homeless community, and maybe there could be someone in a team who has a special interest and links up with my team, and that would help us to be more aware of what cancer nurses specialists can do and maybe be more aware of the signs to look out for in clients,’ she says.

Her colleague Sophie Parkinson, who works on the acute side as a nurse practitioner for the Kings Health Partners homeless team at Guy’s and St Thomas’, shares her experience. ‘We get a high percentage of people who have cancer. Usually they have had a late diagnosis.

‘One of the trickiest things is that people are not recognised as being palliative until they get to end of life, because their life expectancy is so low,’ she says.

• RELATED: NHS must tackle shocking inequalities for homeless people, say healthcare workers

This can be because signs of malignancy have been confused with the effects of chaotic and harmful lifestyles. But it means they do not have the same chance for recovery or palliative care as those in the general population.

Ms Parkinson says: ‘I see people with significant weight loss who I straight away think have signs of underlying malignancy, and other people have confused this symptom with the life of a drug user, for example, thinking: “He doesn’t eat well. If he wasn’t homeless he wouldn’t have lost so much weight.” There is a lot of stigma.’

Her multidisciplinary service is one of 11 inpatient teams across the UK set up by homeless health charity Pathway to pioneer a nationwide model for integrating specialist homeless services into NHS acute hospitals. The King’s Health Partners Pathway team works across Guy’s and St Thomas’, Kings College London and South London and Maudsley NHS trusts.

Better links with palliative care nurses

She advocates for a focus on preventing homeless people from falling through the gaps with regard to their health needs.

Ms Parkinson describes seeing a rough sleeping patient in his early forties who was discharged after receiving a liver drain, then readmitted to intensive care two weeks later. He died from end stage liver cancer three days after being referred to palliative care.

‘I am trying to strengthen links with palliative care nurses. We both feel we don’t work closely enough,’ she says.

Homeless people face persistent barriers to accessing mainstream primary care services, which means opportunities for early intervention are often missed.

At the charity Homeless Link, head of policy and communications Caroline Bernard says: ‘Primary care and other core health services can sometimes be too exclusionary or inflexible for people who are homeless with complex needs.

‘Instead, homeless people are more likely to come into contact with services when they are in crisis, attending emergency departments to patch up their conditions before being discharged back onto the streets.’

She calls for more flexible primary care services and for an expansion of specialist homeless health services that have developed in pockets where there are high levels of homelessness.

Lack of access to specialist support

At national charity Crisis, chief executive Jon Sparkes agrees. ‘Things most people take for granted, like registering with a GP and receiving information about follow-up appointments, can be made nearly impossible for someone sleeping rough or in temporary accommodation, for reasons as basic as not having an address.

‘And even when people do manage to receive care, they often don’t have access to the specialist support they need.’

Once someone who is homeless receives a cancer diagnosis they should be placed on the two-week cancer referral timeline. Homelessness is not referenced in the National Cancer Strategy, but the government’s Rough Sleeping Strategy – the vision to end rough sleeping by 2027 – places a duty on local authorities to house people who are vulnerable for health reasons.

Accommodation during treatment

Macmillan Cancer Support director of policy Moira Fraser-Pearce says: ‘It is vital that those diagnosed with cancer who are most vulnerable are given additional support, including effective housing support from their local authority, to ensure they are able to get timely and appropriate treatment and support.’

• RELATED: New 'duty to refer' homeless act emphasises role of nurses

But with a national shortage of social housing, finding appropriate accommodation during treatment – particularly if people have drug and alcohol addictions – remains a major challenge, says GP Caroline Shulman, clinical lead for a homeless health team in London.

‘There is a lack of appropriate places for these people to go, and they may be far away from treatment,’ says Dr Shulman.

Reluctance to engage with cancer services

‘There would be a reluctance to start treatment, such as chemotherapy, if the person is on the street because the immune system is too compromised.’

There may also be challenges with persuading homeless patients to engage with cancer services.

‘People who are homeless are a vulnerable and complex patient group. Some people may be ashamed to go into hospital because they feel too dirty, or they may worry that their addictions will not be met and they will suffer from withdrawal,’ says Dr Shulman.

Palliative care nurse Alison Colclough is involved in a project funded by the Rayne Foundation that tackles inequalities in end of life care for people who are homeless. She works two days a week for St Luke’s Hospice in Cheshire to provide outreach support to staff at homeless hostels.

She is trying to strengthen links between hospices and hostels to broaden the support options available to homeless people, so they have choices about their end of life care.

An extra advocate

‘I’m supporting people in hostels with a palliative diagnosis to get them into services, such as working with social workers to get them into supported accommodation and making sure they are linked with district nurses and Macmillan nurses if they have cancer,’ says Ms Colclough.

Many people she sees are too young to be eligible for sheltered accommodation. They can be supported for longer in hostels for homeless people, until they are nearer the end of life, but if there are issues such as drug and alcohol addiction, staff may need to put in place additional measures, such as locked medicine cabinets that only nurses can access, to prevent theft of drugs.

‘I helped one young man die in a hostel bed by having a locked cabinet system. It can be done, but it is a huge ask on the hostel staff.

‘Another patient I supported at the hostel died peacefully with us at the hospice. That wouldn’t have happened if all the links hadn’t been put in place. It’s having the extra advocate in the loop that makes all the difference.’

Louise Hunt is a health journalist

Homelessness will be a matter for discussion at this year's RCN Congress, which takes place in Liverpool from 19-23 May. The matter was proposed by RCN North Yorkshire Branch in the hope that Congress discusses the health and well-being impact on families and individuals without a secure, affordable home. For more details, go to: https://www.rcn.org.uk/congress/whats-on/debates

Find out more

• Ministry of Housing, Communities and Local Government (2018) The Rough Sleeping Strategy
• Office for National Statistics (2018) Deaths of Homeless People in England and Wales: 2013-17
• Wellcome Open Research (2019) Causes of Death Among Homeless People: a Population-based Cross-sectional Study of Linked Hospitalisation and Mortality Data in England