With increasingly unpredictable weather patterns, a growing homeless population, and spiralling living costs, Madeleine Anderson looks at homeless nursing care and the challenges of keeping this vulnerable population safe and healthy during tough winter months.
Nurses working to support a growing homeless population have warned of the ongoing challenges within the sector and the need to ensure care is individualised to each person’s level of trauma and need.
In a series of interviews, Nursing in Practice was told erratic weather patterns are now causing issues throughout the year, including during the summer months, and that the workforce must be ‘agile’ and ‘flexible’ to meet the impact of this on people who are homeless and street-homeless.
Concerns were also raised around ongoing stigma facing this population and the impact this can have on self-administering vital medications, especially because some individuals fear this could be misinterpreted as recreational drug use.
Nurses also discussed the need to have a slower approach to build the trust of patients and to provide effective long-term support for diverse homeless populations.
Thinking outside the box
Dom Lenaghan is a Queen’s Nurse and lead nurse for the Wandsworth, Hammersmith and Fulham Homeless Health Service at the Central London Community Healthcare (CLCH) NHS Trust.
He told Nursing in Practice that the complexity of issues, including life-limiting conditions like diabetes and addiction, faced by patients is ‘increasing’ and stressed the importance of care to be individualised to each patient’s level of trauma and need.
‘The landscape of homelessness is always evolving, so we need to tailor our service to deliver to the needs of that population at the current time.
‘I think it’s really important to understand that the issue of homelessness is not going away anytime soon,’ he said.
Late last year, research from the homeless charity Shelter found that at least 354,000 people in England, including 161,500 children, would be spending Christmas 2024 without a home – a 14% increase in one year.
This includes a 17% increase in people living in temporary accommodation (326,000) and a 10% increase in those sleeping rough on any given night (3,900).
According to the homeless charity St Mungo’s, 79% of people on the supported housing pathway in Hammersmith and Fulham have at least one long-term health condition and have a greater reliance on emergency health services given their lower life expectancy and struggle to access health services.
Mr Lenaghan said Hammersmith and Fulham had seen a four-fold increase in nurse contacts with patients in the last 12 months and told Nursing in Practice that ‘out of the box thinking’ was key to tackling health inequalities across society.
‘I like the out of the box thinking that we often have to do. As a society we’re often all put into boxes and not everyone fits those boxes, so I like the fact that I’m able to look at that and try and work out other ways to get people back engaged with their health,’ the lead nurse explained.
A slower approach
Mr Lenaghan says a slower approach is needed to build the trust of patients and to provide effective long-term support for diverse homeless populations.
He suggested that many people who are homeless, especially those who sleep rough or have previous health-related traumas, are wary of receiving healthcare support and registering with primary care services.
‘It’s about reminding ourselves as professionals that we have an agenda, but our patients also have their own priorities that they may need to deal with first before they see us,’ he explained.
‘Especially for our rough sleeping population, safety is paramount, so actually they’re trying to make sure they’re warm and they’ve got something to eat, so actually health is lower down the list.’
According to the Care Quality Commission, the average age of death among homeless people in the UK is 47 for a man and 43 for a woman. This compares with 79.5 for men and 83.1 for women in the general population.
Mr Lenaghan spends a lot of time advocating for patients and working with local GPs to ensure patients are registered and receiving the primary care support that they need.
‘It’s important to remember that people who are experiencing homelessness are still people, and they still have the same issues that me and you might have,’ he said.
‘They also have added complexities through previous trauma that we need to work through with them.’
Mr Lenaghan also described how the stigma around homelessness can impact whether individual’s feel confident when self-administering medication, such as insulin, without a fear of judgement or the worry that this will be misinterpreted as recreational drug use.
Earlier this year, a report from homeless charities Crisis and Pathway found that only 9% of health professional respondents felt their specialist community nursing services provided enough provision.
The survey, of 156 health professionals in England, found that even less (2.6%) of respondents felt their community health visiting services provided enough care provision for homeless people locally.
The impact of climate change
Erratic weather patterns are also making it even harder for homeless nursing teams to prepare for the varying health needs of their local homeless populations and are now causing issues throughout the year.
‘When I first started this job, we only thought about severe weather protocols in the winter, but I think it’s key to say we also now have severe weather protocols in the summer, which we didn’t used to have,’ Mr Lenaghan explained.
Unpredictable weather, including heavy rain fall and sudden temperature changes, has a particularly harsh impact on rough sleeping populations and those who cannot easily store medicines or health supplies.
Earlier today the UK Health Security Agency (UKHSA) issued a Cold Weather Alert for all regions of England, with forecast low temperatures expected to put extra pressures on health care services.
Kirit Sembhi, a homeless and inclusion health project lead at the Queen’s Nursing Institute (QNI), shared Mr Lenaghan’s alarm at the growing impact of extreme weather on homeless nursing.
While she recognised that hospital nurses are impacted by seasonal changes, she stressed that day to day weather changes have a particular impact on community nurses.
‘I think this particular workforce has to be really agile and really flexible to the changing weather and climate, they’ve got to be really quick in changing their services for their client group,’ she said.
Jacqui Conaty is a Homeless and Inclusion Health Nurse at Pathway, the UK’s leading homeless and inclusion health charity.
She echoed Ms Simbhi’s concerns and also warned that the current housing crisis is pushing many more people in the private rental market towards first-time homelessness that has a knock-on effect on health.
‘Without healthy housing you’ve got unhealthy healthcare as well,’ she said.
In October 2024, the government confirmed that the amount of housing benefit that private renters can claim will be frozen again, meaning benefits payments will not keep in line with rent rises.
And in April, a London Councils spokesperson warned of a £700m black hole in social housing budgets across London boroughs over the next four years.
There are currently over 320,000 London households on a social housing waiting list, and London Council’s estimates that one in 50 Londoners are homeless and living in temporary accommodation arranged by their borough.
In September, the Queen’s Nursing Institute (QNI) published new guidance for nurses and allied health professionals caring for people with diabetes who are experiencing homelessness.
Last year, a study into primary care access for homeless people during the pandemic found that remote consultations had become common for homeless people, potentially exacerbating inequality in healthcare access.
