Homelessness and health: what can be done in general practice?

Abstract

In England between January and March 2003, 31 470 households were newly accepted by local authorities as homeless.1 The large and increasing numbers of people so categorized have complex health, social and psychological needs, and in the past decade numerous centres have been established to provide primary care to homeless populations.2 Personal medical services legislation has made this possible; previously, the system of general practitioner (GP) fundholding was an obstacle to primary care for homeless people with complex problems.3 The new nationally enhanced GP contract will probably offer incentives for care of homeless people.4 What are the existing barriers for this group? In a report to the Office of the Deputy Prime Minister, they included surgery opening times, appointment procedures, location, financial disincentives and discrimination.5 Reasons for discrimination include perceptions that they are migrant, violent, antisocial or ‘undeserving’.6,7 Additionally, we contend that some homeless people face a further risk of exclusion because of their age, gender, ethnic background or sexual orientation. In primary care, challenging behaviour can be an issue, but categorization of an individual as ‘deserving’ or ‘undeserving’ takes no account of the societal factors such as unemployment and poverty that can lead to homelessness.8 The General Medical Council exhorts doctors not to allow personal views about patients' race, culture, gender, sexuality or age to prejudice the care they receive.9 This places a challenge to clinicians not to exclude people from healthcare on account of homelessness or possible drug-using culture. A comprehensive account of the management of the common health problems associated with homelessness is beyond the scope of this paper. Here we seek to describe the principles of best practice.