Sleeping rough during Covid-19 and beyond: a public health emergency?

Key:

• HM:     Helen McKenna

• LC:      Dame Louise Casey

• CS:      Dr Caroline Shulman

• PA:      Paul Atherton

HM:       Hello and welcome to the King’s Fund podcast.  I’m Helen McKenna and I’m your host for this episode.  Today we’re thinking about the health of those who sleep rough.  Listeners will be aware that rough sleeping remains a huge problem in England with the latest government estimates suggesting that in 2019 around 4250 people were sleeping on the streets, although the real number may be much higher.  The issue became even more prominent during the Coronavirus pandemic as the government sought to protect those sleeping rough from catching the virus and spreading it on to others.  In recognition of just how vulnerable this population is, the government launched ‘Everyone In’, an initiative aimed at putting everyone sleeping on the streets into emergency accommodation.

And a recent report by the National Audit Office suggested that the scheme made a huge difference.  By November last year, it had reportedly helped over 33,000 people.  However, finding long term solutions to supporting those who sleep rough is about so much more than just putting a roof over people’s heads.  People who have slept on the streets often have multiple complex needs and addressing them involves looking at all the factors that make up an individual’s life.  That includes their social wellbeing, their education and employment opportunities, their housing and, of course, their physical and mental health.  And that last point is what we’re going to focus on today.

People who sleep rough have some of the worst health outcomes in England and so supporting those health needs is a critical part of the picture when thinking about rough sleeping.  We’ll consider in this episode what some of those health needs are, as well as what services can do to support them.  And to help us explore this, I’ll be speaking with several experts, two by virtue of the work they have done in health and homelessness and one through his own personal experience.

First, let’s start with some context and the inside story of the Everyone In initiative.  And to help us with that, let’s hear from Dame Louise Casey.  So, Dame Louise, back in February last year, you were appointed by the Prime Minister to lead a review into the causes of rough sleeping and then very shortly after that COVID-19 hit.  And your role suddenly became one of crisis management and leading Everyone In initiative?  That must have been such a huge challenge?  Can you tell us, briefly, about Everyone In and the approach you took?

LC:         Essentially, what had happened is, I was actually doing some work in Australia and Sydney in the fortnight before we went into lockdown.  And I flew back into the country having basically been in a hotel in Sydney, they, very kindly, put me up in a hotel.  And the hotel had emptied and there were plenty of vacancies in said hotel.  And they also put just extraordinary, fantastic, literature, in the room, in many different languages, telling us that they would look after us were we to get any symptoms.  So, hotels were pretty high in my mind.  Then, of course, I got home and I actually … for all sorts of reasons, I basically bustled my way into the Ministry for Housing and Local Government, it’s my former department, so, they know me well in there.  And I said to Robert Jenrick, you know, “Do you want a hand?”  And he said, “Good God, yes.”  And so, that’s it really.

I just, sort of, rolled up my sleeves and got on with the job.  And, I think, I find it really interesting that the simplicity of, “This is a public health emergency, we have a virus, it is going to kill people, you have a fighting chance of not letting it kill you if you are able to self-isolate at home and get well.”  So, it was a really simple, and straightforward, thing that we were doing is I was just working with colleagues to try and stay ahead of the virus, essentially, and to move, really, really, quickly.  So, the job wasn’t to end rough sleeping, I wasn’t the homelessness Tsar as I was 20 years ago.  I was, essentially, at the beginning, anyway, a volunteer, that was advising everybody on how we could move as quickly as humanly possible.  And, you know, the Damehood comes in useful occasionally when you want to ring the Chief Exec of the Travelodge.  Potentially they might be more likely to take a call from me than they might be if I was, you know, a different person.  So, you know, we just threw everything that we had at it.

HM:       So, you really were on the phone to yourself doing some of this?

LC:         Oh, my God, yes, it was relentless.  I mean, I’m not exactly a patient person.  So, you know, if I thought somebody wasn’t going to do it, I would ring them myself.  And, you know, I wasn’t taking no for an answer.  The fascinating thing was, of course, we needed such a volume.  Because, by then, we were working hand in glove with colleagues in health.  No, I’ll be honest with you, 23 years in Whitehall, Home Office is pretty impenetrable, the Health Department is impenetrable.  It is like … you know, it’s not … because, of course, it runs the NHS.  I mean, you know, it runs the national … as I would call it the National Hospital Service but that’s probably for another podcast.

But essentially, I think, it was so important because none of us on this side, on the civilian side of the shop, we could get the hotels.  Everybody was putting their … you know, every local authority in the country went into overdrive.  But, of course, we had to manage it on health lines.  And I thought that was a huge challenge, actually, that we had to have some hotels that could take people that were symptomatic, COVID symptomatic.  We had to have other hotels that could take people with underlying conditions and/or very significant drug, alcohol, and mental health, problems.  And then we had to have other hotels that would feed people who were asymptomatic and also had no underlying conditions.  Because it was clear that we couldn’t mix the three.

That’s a huge ask of the charitable sector, to do that.  And it was the charitable sector that did it.  It’s not like the NHS did it, you know?  We begged and borrowed people like Ed Storey, fantastic, NHS doctor.  And, you know, the other thing was, of course, people could self-isolate in their own homes with the support of friends and family.  Even when they got sick, you were able, and still are able, to keep people at home, right up until the last minute.  Well, you can’t do that in homelessness.

HM:       So, are you able to identify what made it such a success, the Everyone In initiative?

LC:         You know, there’s something really interesting here about the fact it was a health emergency.  So, we know, for example, that people who sleep on the streets are … I think it’s 86% will have a drug, alcohol, and/or mental health problem.  And yet it took this type of health emergency to essentially just make it really clear that we weren’t going to have people on the streets and we didn’t want people in communal night shelters.  And I think that’s interesting in itself.  And I think it has proven a point really which is we reduce the number of people sleeping rough on the streets in the UK down to the hundreds, 20 years ago, we did it in 2020, for different reasons, but we did it, and it was possible.  And I think it gives you a real sense that nothing is ever impossible, everything is possible.  We are all human beings and we all have frailties which means at different points in our lives, we need different things.  But in terms of big government problems, rough sleeping is solvable.  We’ve proven it twice now.

HM:       So, I was just going to ask, because you’ve mentioned about homelessness or rough sleeping and especially during COVID as a, kind of, public health emergency.  And I saw you talk about … I think there was an article where you described street homelessness as a public health issue?  And I would just be really interested to hear a little bit more from you about that relationship between health and housing.  Because, as we know, it’s so complex and one can lead to the other and the other way round.  Tell me a bit more about your thinking?

LC:         So, I think, what’s interesting is the support for Everyone In was universal, you know?  The government wanted it to happen, everybody in local government wanted it to happen.  Everybody in the charitable sector wanted it to happen.  And, to be honest, once, you know, you explain to somebody on the street what’s going on, they will … you know, at that point, they would come in, because people were fearful of getting the virus and also dying from it.  I think what’s profoundly interesting though is that if you look at the people who are long term rough sleepers, so, we know in London, for example, that there are upwards of 2000 people now who have been on and off the streets or pretty much on the streets for over two years, we know that 86% of those people have very significant health problems, e.g. drug and alcohol addiction and mental health and, you know, you don’t need to look to hard to see the physical toll that sleeping on the street takes.  We still, remember, have people that die on the streets.

And, I think, the difference between what happened last year and what happens in peace time, as it were, is that my drug addiction is mine and I’m not going to spread it to you, whereas, my virus, I can spread to you.  So, the people who are unhoused can spread the virus to the housed.  And, I think, that’s where we ought to come back to, if we looked at, particularly, rough sleeping and particularly children growing up in cramped and overcrowded conditions like bed and breakfast hotels, converted office blocks, the, sorts of, things that we know homeless families are living with, you could actually quantify the health deterioration in those families and make a choice that you would see that as a health issue not a housing issue.  That actually making sure people live in reasonable conditions, even if they’re temporary, is so important in terms of the health and wellbeing of those children.

So, I felt, having done the rough sleepers’ job under the Blair administration so many years ago and reaching a certain level of success, I think in that rough sleepers’ initiative we did things like use that funding for drug and alcohol treatment.  So, we used, essentially, housing and homelessness money to purchase health related money.  There is a really important learning, I think, when we come out of all of this about trying to look at what health is and where health spend is and how we do it and that, at the moment, the Ministry for Housing & Local Government’s finances are actually paying for health services for homeless people.  And there are days when I wonder, actually, Helen, whether, actually, you could say, as a government, “Do you know what, we’re going to move over the responsibility for rough sleeping and for families that are in long term appalling accommodation, we’re going to hand that over to Health, because, actually, that’s as much of a health issue as anything else.”

HM:       There’s so many issues, actually, that are like that, as well, where there’s a public health … the wider determinant.  They’re all so interlinked.  And, actually, where do those boundaries end and where does health begin?  And they’re so permeable.  You mentioned that you were working with some NHS doctors, were health and care services formally involved in the Everyone In initiative and, if so, how did they respond?

LC:         Well yes, they were.  To be fair, in London, Gemma Gilbert is the London Health Partnership’s … and frankly deserves a medal.  She opened up the door, as it were, and recognised the need and was able to deploy the NHS in London towards those services.  So, it was a formal thing, not just Andrew Hayward and Ed at the beginning with me and John from Crisis and Jeremy Swain and a few … you know, we were all on calls, early on, trying to figure out how to do this cohorting.  And St. Mungo’s led a huge amount of that work, actually, that we’d have been lost without them.  But then it became clear that, you know, things like PPE and all of those, sorts of, things, you know, we have volunteers and frontline workers, essentially, fronting up hotels.

We ended up with a scenario where the NHS paid to get Médecins Sans Frontières, actually, to help staff a particular hostel, a hotel, because, of course, it was in the NHS’s interest, to be fair, to keep those people out of hospital for as long as possible and if we didn’t have that level of support then they would have had to go into hospital.  So, it was, in my career, the only time I think where there was such united working on a health and homelessness agenda in that way.

HM:       Thank you Dame Louise.  And we’ll be picking up with her again, in a bit, to get her advice for Sir Simon Stevens, Chief Executive of NHS England and NHS Improvement on what the NHS can do to support this agenda and also get her take on whether the government will be able to meet its commitment to end rough sleeping by 2024.  But first, let’s speak to Dr Caroline Shulman about what some of the specific health needs are of people who sleep rough.

CS:         I’m Caroline Shulman, I’m a clinician and a researcher.  So, a GP, worked in inclusion health for around the last 12 years.  Inclusion health encompasses people experiencing homelessness, people who are marginalised, other groups, such as, asylum seekers, refugees.  And I also have been doing some research on palliative care, and homelessness, and frailty, and homelessness.

HM:       So, Caroline, there are some really stark differences, as I understand it, in terms of health outcomes for the general population and then for those who sleep rough?  What tends to be the main health differences you observe between this population and the general population?

CS:         Well people experiencing homelessness die, often, extremely young.  So, we often see people dying actually in their twenties, thirties, forties.  And the average age of death for people who have been on the street, who are on the street, or in emergency accommodation is often in their forties.  And we know, also, from other data, from hospitals, that people often die 20 to 30 years younger than housed populations.  And the reasons for these deaths are often there’s a range of different things.  But most long-term conditions are worse in people experiencing homelessness.

So, for example, there’s six times more heart disease, there’s, at least, six times more respiratory disease.  People die, also, from HIV, and hepatitis, and there’s hugely more, like, seven times more.  And mental health problems are a huge problem.  So, a lot of suicides, I think, fourteen times more than the rest of the population.  But, also, the reasons that people are homeless are often associated with addictions and mental health problems.  And we know that there’s a huge, vast, increased, risk of dying from drug use.  We also see a lot of premature ageing in people who are homeless.  We’ve recently done some work in our hostel in London which although the average age of people that we saw were 55, it was a hostel with people with a long history of rough sleeping.  They had average frailty scores, equivalent to what you’d expect people in their very late eighties.

And a wide range of other conditions that you would normally expect in older populations, such as, falls, and mobility problems, and cognitive impairments.  So, dementia, early onset dementia.  And the average number of conditions per person was over seven which is off the scale from a housed population.

HM:       What was really interesting in your first answer was just around the link you made between drug addiction and mental health issues sometimes playing a role and leading people to become homeless in the first place.  And I was just wondering, is that a broader issue, that relationship between health and rough sleeping in that health issues can often predate or lead to become a causal factor for people becoming homeless, in the first place?

CS:         Absolutely.  So, we know that many people who end up homeless have experienced a lot of trauma in their early years.  So, we know that adverse child experiences which includes things such as children experiencing neglect, or abuse, in the home, or living with a parent with an addiction, or a parent with mental health problems, can … is a very high-risk factor for them then becoming homeless themselves.  And often those factors as well independently are then related to mental health problems in an adult and addictions in an adult, often the addictions to blank out past trauma or as a way of self-soothing.

But, in addition, certainly people with other physical health problems fall out of work, if the work is unstable, and insecure, with zero hours contracts, then people also become homeless through ill health in that way.  But poverty is an overriding risk factor for homelessness as well.  And we know that poverty is associated with a lot of profound ill health.

HM:       And to what extent for those people who do have mental illness, who have addictions, that then leads to them becoming homeless, to what extent have those people, prior to becoming homeless, been let down by health services, and other services, in getting the support that they need in order to not then become homeless?

CS:         Yes.  I think there’s years of neglect, I suppose, in a way, by the services that should be there to support people.  I think it starts very early on in childhood.  We know that children who are excluded from school have a very, very, high risk of homelessness.  We also know there’s actually quite a lot of missed learning difficulties amongst people who end up homeless.  Autism, ADHD, there’s growing evidence, a growing body of evidence, that, actually, people have just not had their issues and their problems diagnosed.  And that’s also another risk factor for them becoming homeless.

There needs to be much more support, I think, early on, for children in difficulty and, also, for families in need, families living in poverty.  So, I think, there’s many places where interventions need to happen.  We also know that many people go to their GPs when they are at risk of homelessness or are homeless and it’s actually really important that GPs are really aware and do everything they can to support people with letters, and with support, for applications into appropriate housing.

HM:       And what’s the potential role for GPs there?  I mean, do they have links in with other services, with local authorities and are they able to make those contacts to support people who present to them, initially, with that risk of becoming homeless?

CS:         Yes, there’s quite a lot that GPs can do.  GPs can support people, particularly people who have had health problems.  They can help with priority need letters, they can help with letters outlining the risks of homelessness for this person.  But any letter from a doctor to support the absolute need for somebody to be helped with accommodation, they are read, they are looked at, and they are important.

HM:       Great, thank you.  Caroline, what about the factors that affect the health of rough sleepers?  Is it more than just access to medical services?

CS:         There’s many things, I think, that affect rough sleepers, in terms of their health, and there’s many things, I think, that the Health Service can be doing more for.  One thing is that we need to be ensuring that people are able to register with GPs.  And there has been a big barrier and there still is a barrier.  And a lot of practices are actually not enabling people to register easily.  There’s actually no need for people to provide a proof of address or proof of ID at all.  But they are still being often asked to.  There’s also a lot of digital exclusion at the moment with COVID as well.  But, in addition to that, I think they have to be enabled to have really person-centred holistic support.

So, we’re often seeing people, as we’ve mentioned, with quite profound difficulties.  Mental health, physical health, often extremely profound physical health problems and also in association often with drug or alcohol addictions.  So, we need to be starting and seeing people from where they are, giving very much a person-centred holistic approach to their healthcare needs.  Developing trust is actually fundamental, it’s a fundamental start, to developing that, sort of, holistic approach to improving and supporting people to recover.  And that can often take quite a long time, and it often can take a lot of time with the same person.  So, it’s really important, I think, when we are, as healthcare professionals, when we are seeing people who have experienced this degree of trauma, and homelessness, that we take that into account and we try and ensure that we are flexible with our systems and our services that people can see the same person regularly and build up that constant trusting relationship.

HM:       So, fascinating that, actually, you know, that sometimes there’s this barrier around rough sleepers or people who are homeless, being able to register with their GP.  And I just wondered, what’s behind that?

CS:         Yes.  That’s a really interesting question and I don’t think we really know.  I think there’s a lot of barriers being put up, I think, by receptionists.  And even when people are accompanied to register with a practice, with a nurse, or an outreach worker, or a peer supporter, they come across barriers.  And those barriers are … I think people are very stigmatised.  People experiencing homelessness have told me that they have been treated very badly.  They have been told that they smell and they should leave the room, that they should go and register elsewhere.  So, we know that there are some fundamental, unlawful, barriers, that are being put up for people to register.  Apart from stigma, I think people also need to recognise that people often who are experiencing homelessness often have quite complex needs.  So, I suppose, in some ways, will take more time to deliver good quality care too.

HM:       And so, does that then require, presumably, training for all members of a general practice team or is it that, actually, these services need to be set up as specialist primary care services for that group and not integrated into the, kind of, general practice, if you know what I mean?

CS:         I think there’s a need for both.  All services, all mainstream services, need to be absolutely aware of the complexity of need of people experiencing homelessness and need to be supportive and inclusive in their practice.  Nobody should be turned away, everybody should be given the respect that they need and they deserve.  In addition to that, I know that some people really do prefer and find it much easier to engage in services which are specialist services.  And I worked, for many years, in a specialist primary care service and I know that most of the people who were registered with us had had poor experience in other mainstream services and that was … and they were really greatly relieved to finally find a service that gave them care and support in a holistic way.

The other thing I’d like to add is that many people living in hostels or other emergency accommodation have often these very profound needs.  And I think it’s really important that primary care does recognise that and it does in reach into these facilities, because it’s really important, where possible, to try and take the care and support to people, rather than expect them to have to come to see us in our practices which can often be … with access, can be really quite challenging.

HM:       What has been happening during the pandemic?  So, obviously, we’ve spent almost a year now living with COVID.  Has there been particular health support offered to rough sleepers during the pandemic?  Was it part of the government’s Everyone In initiative?

CS:         Yes, very much.  I think it has been an extraordinary year, extraordinary number of months since COVID hit.  And with an overwhelming response, actually, initially, to be honest, from the government, in supporting people to get inside and off the streets.  Because we know that, obviously, things like night shelters, overcrowded accommodation, was clearly not a possibility.  And so, certainly in London alone, I think 7000 people were found emergency accommodation which shows how many people actually were on the street, huge numbers of people on the street and more flowing to the street with economic problems from COVID.

So, a huge monumental effort on the part of local authorities, GLA, and others, to find accommodation for people.  The health response was fantastic, in some places, but patchy in others.  So, it was very variable, actually.  There was a huge attempt to try and get support, so, get people … or register with GPs.  But we know that there’s still about 20% are not registered with GPs.  Some areas provided in reach support into the hotels because this was a massive opportunity to really help provide that wrap around health and support and identify unmet health needs, and address them while people were inside.  And, in some areas, that was done fantastically.

The areas that responded better were those that had a specialist service, already in place.  So, where there were specialist GP practices, it was quite easy to identify services that could be boosted to then do in reach into the hotels.  Where there was no particular specialist interest in this, there … I think it was very difficult for commissioners to actually identify who could provide that support.  The other thing is, obviously, all services have been under huge pressure and including primary care and I think it was felt, by some services, that they just couldn’t manage to do extra in reach or support.

HM:       And where are we now?  In your opinion, do you think the Everyone In initiative will make a long-term difference to rough sleepers and those at risk of becoming rough sleepers in terms of preventing them from returning to the streets?

CS:         Yes, absolutely.  We know that, already, some people have been supported into longer term accommodation which is fantastic.  I hope that they’re going to receive the support that they need in that longer term accommodation.  So, I’m optimistic that if the supports are there for people then that can be their end to homelessness and they move onwards and upwards.  We know that there are some fantastic success stories that many people having a roof over their head, having food, not struggling with what they’re going to do everyday to be able to survive, were also able to reflect on where they were and move forward and onwards and out of homelessness.

There was also an excellent responsive ability to get people linked in with addiction services.  So, there was … the addiction services really stepped up in London as well to support people.  And so, we know that the Everyone In really, really, did help to turn many people’s lives around.  And I hope that for many that will be a very long-term gain and it will remain.  That’s not the case for everybody and for some people the hotels were not providing the same amount … the degree of support and they didn’t work out for people, and people ended up back on the street, in some areas.

HM:       More broadly, how can the NHS work with others to improve the health of people sleeping rough?

CS:         So, I think, the role of the NHS is to ensure that everyone is registered with a GP and has access to inclusive primary healthcare.  The NHS also can support getting people into accommodation by advocating for people but also advocating with other organisations, ensuring that there’s really joined up support with social care, with addiction services, with mental health services.  The other way the NHS can help is by actually doing much more in reach into areas where there are high rates of homelessness.  The other thing I think the NHS can do is consider working more with peer led organisations such as ground swell.  So, really, ensuring that the voice of people experiencing homelessness is heard with our service development, our service provision, but, also, the support of individuals.  So, ground swell, peers, for example, can support people to attend appointments and to provide that support that often others are not there to provide.

HM:       Thanks Caroline.  So, we’ve heard about some of the factors affecting people sleeping rough and what health and care services did during the pandemic.  But what was it like to experience Everyone In from a personal perspective?  Our next guest is Paul Atherton who talks us through his lived experience with homelessness.

PA:         My name is Paul Atherton.  Film Producer, Playwright, creative generally, dogsbody.  I specialise in social commentary.  For the last eleven years now, I have been absent without a home.  Being homeless is absent of a home and not necessarily street homeless.  So, if somebody is sofa surfing, they are homeless, if somebody is in temporary accommodation, they are homeless.  So, in my journey, over that eleven years, I have been four, or five, months in a No Second Night Out shelter hub.  I have lived in my car for two years, I have slept at Heathrow Airport for two years.  I have spent about a year and a half at a night shelter in Dacorum in Hertfordshire.  I have sofa surfed on friends’ floors.  I have slept on night buses and night tubes.  And very, very, rarely, I have actually slept on the street.

I am currently residing in hotel accommodation in Marylebone in Central London as part of the Everyone In government initiative but I’m only here until 6 January 2021 when I return to the streets.

HM:       Thanks Paul.  And can you tell me a bit about when you first became homeless, what was going on for you, at that time?

PA:         Sure.  I was living in an apartment.  My flatmate and I were very happy there but she decided to move on.  So, I was going to take over the tenancy.  I did my usual due diligence, checked my credit file reports and discovered that an erroneous piece of information, a mistake, had been apportioned to my file.  And that impacted my credit score hugely taking me down from a gold or a green to a red or a black.  Annoyingly, I had already had this piece of information removed off both my credit files four years earlier.  Both the companies that investigated proved it had nothing to do with me whatsoever and removed it.

So, when I discovered this, I went back and said, “Take this damn thing off, you know this has got nothing to do with me, here’s the evidence from the last time we went through this fiasco.”  And they both said, “No.”  So, I said, “Well then there must be somebody who has more authority than you, if you’re refusing to do this?”  And they said, “It’s the Information Commissioner’s Office, the ICO.”  And I wrote to them saying ‘Look, this is all the evidence, this is all the facts, could you please do something, because I need to renew my tenancy in about six weeks?’  And they said ‘Well we take 28 days to sort this out.’

18 months later, I get a letter from the ICO saying ‘Dear Mr Atherton, we apologise for the delay.  We’ve had a significant backlog, but we can assure you we have investigated your claim, you’re absolutely accurate.  And we have advised both the companies that investigated to remove this off your file immediately.’  Well 18 months was way, way, too long.  So, obviously, my estate agent couldn’t renew.  The stress of that prompted my condition and I suffer with a disability known as chronic fatigue syndrome, to flare up.  I then spent three months in hospital and I was discharged from hospital into a homeless hostel in Brixton.  And thus, began my homeless journey.

HM:       I guess interesting that health was part of the story that precipitated you then becoming homeless?

PA:         Yes.  I mean, I was diagnosed with chronic fatigue syndrome back when I was in university when I was about 21, 22.  So, I spent about six weeks, I think, eight weeks, in hospital, and then I was discharged back to the flat where I was living with my girlfriend who was a nurse.  And she looked after me for nigh on 18 months I was bedridden, for the first bout.  And they believe that that had been triggered by my glandular fever when I was ten.  So, that condition has been something I’ve had to manage ever since.  So, regardless of whether I’ve had a home or I’ve been absent of one, my fluctuating remitting condition, when it comes to symptoms, means that, you know, there are times when I’m completely bedridden, unable to speak, unable to move, and I am utterly and totally reliant then on friends.

HM:       And does your condition … does it also get made worse by the stresses of not having a permanent home?

PA:         Yes.  I mean, basically, every doctor you will ever talk to about chronic fatigue will always start off with, “Well, you must diminish your stress levels.”  And you’re like, “Alright, well, you know, give me a place to live would be a good start in that equation.”  Yes.  So, like nearly any condition, you know, stress plays a factor in flaring up symptoms, yes.  So, the condition is absolutely, absolutely, impinged by stress, and stress factors.  Ironically, being absent of a home per se is the least of the stress factors that is involved with homelessness.  The real stress factors are having your benefits stopped because you are too sick to attend a medical that’s there to assess how sick you are.  And you’re like going, right … and suddenly your only means of feeding yourself has completely vanished.

Or the bureaucratic nonsense that you have to go through, spending hours, and hours, and hours, writing to a council to get assistance through the local authority, only for them (a) not to read the e-mails and (b) then to, sort of, just point blank refuse to help or to not answer questions.  So, it’s those frustrations that create immense amounts of stress and then that stress level then prompts the symptoms of chronic.  And then you find yourself in this descending spiral where you actually … the one thing you needed was help and support and it’s the last thing anybody has given you, until you eventually end up being completely reliant on somebody wheeling you, or, you know, sort of, ringing an ambulance to take you into hospital.

HM:       And you mentioned that you had been hospitalised, for some weeks, kind of, early on?  Have you been hospitalised since then?

PA:         Well, the long stint that I’ve had in hospital was the three months that I was at St. Thomas’s.  That then became a war of attrition about bed blocking.  Because chronic fatigue is an incurable and an untreatable disease.  So, as soon as you, sort of, encounter the hospital system, they immediately are going to try and get you out of the door, before admitting you, as soon as they realise that you are homeless.  And the attitude at front desk changes.  They are suddenly not convinced that there is anything wrong with you and you are just trying to blag a bed for the night.

I was taken in because I was suffering with breathing difficulties.  And they got a false test on some lung condition that they tested for and it had proven positive.  They only took me in on the basis of that but once I was there and they realised a few … I think it was about a week later that they tested again and it came back as a negative, that they went, “Ah, okay, well, we’ve got to get you out now.”  And then the remaining time was purely about clashing with the Discharge Team, the Social Services Team, the local authorities, about who was responsible and who was going to place me where and how.

At that time, I was totally bedridden, so, I was completely reliant on, sort of, nursing staff to, you know, bring food, and bring bed pans, and the like.  Yes, so, they needed to discharge me somewhere where I was going to get appropriate care.  That didn’t actually happen but that was what was supposed to have happened.

HM:       You said that you’ve been put in hotel accommodation during COVID as part of the Everyone In government initiative?  Did you get health support as part of that?  Has there been targeted or proactive health as part of that package of support?

PA:         No.  There was no support whatsoever.  And it has been across the board.  I’m in contact with a lot of people who I was … there was just over 270 of us, I think, taken in from Heathrow Airport.  And I’ve been in touch with people who have been in different hotels and pockets of people who were distributed across London.  And pretty much across the board nobody had any medical assistance.  When they came out to get us from Heathrow, they basically queued us up and they were taking temperatures and asking if people had a cough.  And the queue was really interesting.  This is a classic homeless … people experiencing homeless moment where people in the queue were going, “Do we cough or do we not cough?  Because are they going to take us in if we’re ill or are they going to refuse us if we’re ill?”

And there was that, sort of, whole mental state going … and, eventually, when people figured out that they were just screening us off into three groups, so, that was the vulnerable group, people asymptomatic, people symptomatic, it was, kind of, going, “Right, fine, we’ll just be honest about it.”  But there was a real moment where it was like, “If we’re ill, and we’re not going to get housed, we’re not going to say we’re ill.”  That was the start of it.  But after that, there was absolutely nothing.  And, you know, the mental healthcare was taken away from lots of people.  Obviously, people had drug and alcohol addictions and they were just left to their own devices.

And, invariably, because they were, they then couldn’t deal with being inside.  And you’re, kind of, going … and it’s that classic moment if you’ve ever been through the system with homelessness charities. or homelessness support, is it’s like, “Well, you’ve got to stop drinking, you’ve got to stop taking drugs and you’ve got to get your mental health sorted out before we will help you.”  As if, somehow, a drug addict can just stop or an alcoholic can just stop.  And you’re like going, “That’s not how this works.”  So, no, there was no medical support whatsoever, there was no transitionary support.  I have received no carers here, whatsoever.  Nobody has checked in on me.

I mean, I could have, literally … if it wasn’t for the hotel manager who I’ve got a good relationship with, I could have been dead here, for the entire time, and nobody would have known.

HM:       So, you said before that you’ve got accommodation, I think, until 6 January as part of the Everyone In initiative but that after that there’s just a huge question mark.  So, what next for you?

PA:         So, I have been notified by the hotel manager that Westminster Council are stopping paying the housing benefit on the accommodation that I’m currently in, which ends my time here on 6 January 2021.  However, I’ve not actually been told that by Westminster Council yet.  And Everyone In, I actually started on 3 April and ended on 3 July.  Since 3 July I’ve been, sort of, under this horrendous sword of Damocles whereby I could be thrown out within less than 12 hours.  And that has been, sort of, constant, up until about three weeks ago when I was given the 6 January date.

Now from your mental health perspective, once you’re inside and you are given the taste of, I can cook three times a day, I can just get up in the morning, and get to the shower, chronic fatigue sufferers do everything in really, really, small chunks.  Because we don’t know where our energy levels are going to be, we don’t know how we’re going to feel, we don’t know what our ability is.  For me, at the moment, it’s out of bed, five steps in the shower.  For me at Heathrow it’s 50 steps down to the Piccadilly Line, get the Piccadilly Line tube to King’s Cross, 120 steps from King’s Cross to the leisure centre in King’s Cross, making sure I’ve got my £2.50 to be able to get into a shower.

So, you can imagine, it doesn’t take very much for me not to be able to get a shower.  And so, they’re the big differences.  So, you’ve, sort of, created this static environment where you’ve incorporated your health condition and you are functioning, in fact, thriving.  In fact, I thrive, with, or without, a home.  But it’s easier to thrive with a residence and a shower and a kitchenette.  So, you know, my meals went from a £3 Tesco meal deal to I was eating fruit for breakfast and fresh veg for lunch and dinner and my body didn’t know what hit it for the first three weeks.  So, yes, so, that had a huge impact on both my mental health and my physical health.

And then I realised that from August forward, my benefits were likely to stop as they had done.  So, you start going back to eating £3 meal deals.  And, of course, with that, changes your mental health state.  You suddenly … you just suddenly feel like, well, what’s the point?  What’s the point of trying to struggle through all of this again?  And then, with that comes your physical health drops.  Because your energy drops, because you’re not eating healthily.  And then the depression starts seeping in.  And then, with all of that, having the sword of Damocles of going, “We may be kicking you out” and then not being able to return to Heathrow, because Heathrow is still in lockdown, so, you can only go there now if you are travelling.”  So, my failsafe doesn’t even exist.

So, having had this eight, nine, months, of being inside, I’m now being forced to leave in January in the midst of winter, with nowhere else to go.  And, sort of, mentally, I’m not even thinking about it.  Because to think ahead going, “Well what’s going to happen on 6 Jan” would just mean I’d spend the next four weeks going, “I don’t know what’s happening.”  But, yes, so, I mean, it is the worst of all scenarios when it comes to your health because it’s the precariousness of unknowing what’s coming next.  Now I don’t mind rolling with the punches, it has been my life since I was born.  But when somebody goes, “Right, let’s show you what we could do and look how easy it was to do that.”  So, Everyone In basically did what every homeless person has been saying for decades, it’s like, “Get rid of the bureaucracy, get everybody in, get them the healthcare, and support, that they need, find them accommodation, to their needs, and then we’re sorted, that’s homelessness done.”

And people are like, “Oh, well, we don’t have the money” or, “We don’t have this” or, “We don’t have that.”  Well, everyone proved that was complete nonsense but it did demonstrate that with the right political will, and the right drive, that this was easily accomplishable.  It was, get people out there, get people in, give them the support and we can solve this problem forever, that’s it, you know, we’re done, we will never have homelessness in the UK again.  This was the worst possible thing for the people in my position is that to bring us in for us to then shine and show you just how great we can achieve things, when we have these facilities around us, and then to take it all away and then not just take it all away but make the situation ten times worse than when we came in.

HM:       Thank you Paul.  We recorded with Paul just before Christmas and, at that point in time, he was facing eviction from his temporary accommodation on 6 January with no clarity over what would happen next.  Since then, Paul is in the process of challenging his local council by way of judicial review with the help of legal support.  On this basis, he has had his stay extended until 1 March, however, his future accommodation arrangements remain uncertain.  So, having heard from Paul about his personal experience and Dr Caroline Schulman about some of the specific health needs of those who sleep rough, we are left with a few big questions.  What is the role of the NHS in addressing rough sleeping and will the government manage to hit its target of ending rough sleeping by 2024?  Here’s Dame Louise Casey.

Stepping beyond COVID, in your experience, how well, in general, does the NHS serve the rough sleepers population?

LC:         Not very well.  I mean, look, the NHS, in my view, is the National Hospital Service and anything else around the edges just becomes a side order.  And it’s very hard to say that because one … you know, like everybody, I adore the NHS and everything it stands for and it’s symbolic of a post war Britain that decided to do some really, really, big things, for example, create the National Health Service.  But as long as the National Health Service is essentially managing the symptoms of poor health, we are never going to get to the panacea of actually most health spend being out with hospitals because hospitals are less needed.  And that’s really the goal, isn’t it?  And, actually, that’s very hard to articulate.  And it’s, at the moment, crazy to even think about that because we’re in the middle of a pandemic where we are so lucky in this country that we do have an NHS, and we’re so lucky in this country that it has universal support from all political parties.

But as for the world … I mean, you know, I was in North Camden on Wednesday this week at a community centre, the Queens Crescent Community Centre, the life expectancy of people in that estate is twelve years less than the people ten minutes up the road in Mansfield Road.  It’s what we do about that and the NHS doesn’t march on that, it marches on saving our lives when we go into hospital and thank God it does.  But there’s a gap there, isn’t there, the same way there’s a massive gap around what we really want from social care, and the fact that no government has actually bitten off the nettle of social care and decided to do something about it.

But, you know, I always think that our treatment of the elderly and our treatment of people who are at the stream ends of poverty just leaves an awful lot to be desired in the fifth or six richest country in the world and that’s out with pandemic times.

HM:       And let’s imagine that the NHS England and NHS Improvement Chief Executive, Sir Simon Stevens, is listening to this podcast, what advice would you have for him on what the NHS needs to do, on a rough sleeping agenda?

LC:         God love Simon, at the moment.  He’s up to his eyes in it.  But when the dust settles and we come through this, I think that what we have to look at is the people who the NHS doesn’t touch, both from a prevention point of view or dealing with the symptoms.  Now, let’s be clear, once people are in hostels, NHS engages.  We’ve got some stunning GPs out there.  But what was really interesting about last year was that thousands of those people were not near the NHS and therefore I think that the fact that they came into hotels means that we could get them GPs.  It means that we can not just get them vaccinated for COVID but actually vaccinated and screened for many other things.

I guess my message isn’t just about rough sleeping, to be honest, Helen, it’s about all excluded groups where, actually, a health led approach is often going to be the one that unlocks the door.  Put nurses out in uniforms, on the streets, homeless people respond to them.  They respond to them time, after time, after time.  Some of the most popular people in our day centres are basically the medics and the nurses.  Because it’s a very … it’s an expression of love, isn’t it?  At the end of the day, it’s the way society expresses our love and respect for each other is often through health.  We carry each other through health.  We don’t question it, we don’t judge it.  We don’t think, oh God, she’s a bad person because she smokes all the time.  We can get a bit annoyed about that but we still will look after her and express our solidarity, and support, with her, when she is unwell.

And I think that’s the most important thing about excluded groups is that we consistently show that we will help them and that we are with them and we of them.  And I think that’s the message, basically, to everybody, in public service, right now, is, that’s how we have to come out of this pandemic, we have to come out of it together and not apart.

HM:       And that dealing with need, responding to need, on the basis of need, is a founding principle of the NHS.  I wanted to ask you … so, I saw an interview that you gave back in October last year in which you warned that the UK faces a period of destitution, how worried are you about the future, given the potential long term economic fallout of the pandemic?

LC:         I think the thing is that this has gone on now for quite a long time, you know, to state the obvious.  And there’s no sign of getting back to normal.  And the wounds inflicted by this virus go very, very, deep, into the world of poverty and unemployment and dispossession.  And that, actually, because everybody is concentrating on the virus and, you know, we’re all counting how many people are vaccinated daily and all of those really important things, if you look, for example, you know, let’s take Barking & Dagenham the, kind of, average London borough, it’s not really poor and it’s certainly not rich.  March last year they had 13,000 people on universal credit, October last year they had 34,000 people on universal credit.  In addition to that, in their working population, 40% of their working population was furloughed.

Now those sorts of numbers Helen, like, you know, almost six million on universal credit, over two and a half million unemployed, 4.6 million people being in debt, those are the, sorts of, figures that show you that something really deep is going on and actually just getting out of that is not going to be as straightforward.  So, I continue to be concerned about this short-term ism of, you know, another month, another three months.  Free school meals for another term, people not knowing where they are with the tiny uplift, actually, in universal credit, of the £20 a week, you know?  All of these small things which are really big to the government, you know, we can’t roll back on any of that any time soon.

And we could also choose this moment to actually do a much better job in Britain of looking after the people that are the have nots, you know?  That’s what Brexit told us, that’s what the pandemic is telling us, you know?  We could put aside the extremes of politics and just rebuild a Britain where health is available to all, truly all, where people are not living on benefits that mean they have to go to food banks and that people, where there are no jobs, are getting proper employment training and opportunities so that they can at least see hope for their children, even if they can’t see hope for themselves.  And that’s the Britain that we need to rebuild.

HM:       So, the government has committed to end rough sleeping by the end of this parliament.  I just wanted to ask you, do you think that target can be achieved?

LC:         Not at the moment, no.  Rough sleeping and solving it is like an overflowing bathtub for anybody that has a bath.  And, basically, what it is is, the taps are pouring in and what you do with an overflowing bath in human nature is you actually … the first thing you do is, you switch the taps off.  Nobody is switching the taps off, so, the causes of homelessness continue to flood into the bath.  You then put your … you switch the taps off.  So, you go back to things like … even in the height of the pandemic last year, with Everyone In, there were people being discharged from hospital, and prisons, to the street.

So, if you can’t switch those taps off, you continue to, literally, deal with the symptoms and the symptoms and symptoms of that which is your overflowing bathtub.  And the trick we also need to do is, when that bathtub is full of the same people, for over two years, they’re going to be sick.  I mean you can call it an addiction, you can call it whatever language you want to use about it, but they’re sick.  And when people are sick, you heal them, that’s what you do.  And so, I think, until we’ve gripped those two things which is, you know, how do you really get to people with long term multiple needs, and get them off the street permanently, is more than a hotel bed, you know?  It’s more than a hotel bed.

And how you switch the taps off is profoundly absolutely vital, otherwise you just keep running around and running around opening more and more shelters.  So, their rough sleeping strategy that they published, a couple of years ago, won’t stand the test of that.  And that’s why.  And they know that.  I mean, the Everyone In work and the work that has happened since, will absolutely get those numbers down.  I mean, the numbers are much, much, lower, than they were a year ago.  And that’s not just the work that I was involved in, it’s the work after I’ve gone.  But it won’t solve rough sleeping.

HM:       Thank you.  Despite the success of Everyone In, rough sleeping remains a huge issue with multiple challenges lying ahead.  Taking a holistic approach to the lives of individuals who sleep on the streets that includes responding to their health needs, will be an essential part of any future solutions.  Some progress has clearly been made during COVID-19.  We’ll be looking out for what comes next.

A huge thank you to each of our guests today, Dame Louise Casey, Paul Atherton and Dr Caroline Schulman.

That’s it from us.  You can find show notes for this episode, and all our previous episodes, at www.kingsfund.org.uk/kfpodcast.  We’d love you to subscribe, rate, and review, us, wherever you get your podcasts as it helps others to find us and helps us to improve the show.  You can get in touch with us via Twitter either at the King’s Fund or my account @helenamacarena.  Thanks, as always, to you for listening but also to our podcast team for this episode, Producer Ian Ford, Researcher Jonathan Holmes, and special thanks to my colleagues Ameena Bamel and Julia Cream for their input too.  We hope you can join us next time.