Homelessness: reaching out to the hard to reach

The number of people who are homeless in the UK is growing. Latest figures from Shelter suggest at least 320,000 people now have no permanent address – whether that means sleeping rough, living in temporary accommodation or sofa surfing.

What is equally clear is that this group of individuals have much worse health outcomes than the general population. Average life expectancy for women on the streets is 43 and for men 47. A recent study indicated nearly four in five have significant health problems – and two in five suffer musculoskeletal (MSK) problems, nearly four times greater than the general population.

Homeless people also suffer disproportionately from fractures, acute and chronic soft tissue injuries as well as neurological and mental health problems – many of which physiotherapists are well qualified to help manage.

Yet the truth is that few physiotherapists currently have much to do with the homeless. And this reflects a wider truth, which is that mainstream services as a whole are failing to tackle this pressing but often forgotten healthcare issue.

There is no doubt that homeless people present enormous challenges. Their lack of a permanent address means they may not be registered with a GP and can easily fall off the radar. Their often chaotic lifestyle makes keeping appointments problematic. And many have a deep distrust of statutory services.

Need for physio

Currently they face something of a postcode lottery, with some cities offering a range of services for homeless people while others have almost nothing. Even where such services exist they may not be co-ordinated. And physiotherapy is only rarely part of the package.

One charity that does offer healthcare to homeless people, including physiotherapy, is Crisis, and over Christmas centres in both London and Coventry will be offering access to a range of health professionals.

Jo Dawes, a senior lecturer in physiotherapy at Kingston University and St George’s, University of London, helps run the London physio service with around 20 qualified and student volunteers. Over the course of six days they can see up to 200 patients; ‘so there seems to be a need and a desire for what we offer’.

People present with a range of conditions from MSK to soft tissue damage and rheumatological issues. The team aims to signpost patients to the appropriate services and help with some immediate problems. 

‘We can make sure that the rubber stopper on someone’s walking stick is replaced, for instance,’ says Dawes. ‘We will chat to people and hear what’s wrong with them and give advice. But obviously we can’t offer a programme of treatment that would take several weeks.’

One scheme that does offer that support is Leicester’s Inclusion Healthcare, a specialist GP practice for homeless and vulnerable people which has a physiotherapist on site one morning a week.

MSK physiotherapist Becky Yates, who has been providing this service for the past four years, says the practice introduced in-house physio after finding many of its patients failed to attend mainstream physiotherapy. ‘I can offer flexibility, which is what this patient group needs.’

Her homeless patients present with similar back, knee and hip problems to her other clients – but ‘they tend to have a lot of chronic problems, exacerbated by the way they’re having to live. Often when patients see me it’s the first time they’ve accessed a physio.’ 

She also helps patients access other services. ‘For example, I can refer to a walking aid clinic. I have helped patients in need of orthotics. I can also provide some basic equipment that patients cannot afford to buy. These small things can really improve a patient’s quality of life.’ 

Non-judgemental

Unusually, the service in Leicester is NHS-funded. In contrast another service for the homeless, Streetsmart Physio in Edinburgh, relies entirely on voluntary support.

Streetsmart has been operating in the city for the last 15 years and currently offers two – over-booked - evening clinics a month. Patients are usually referred by GPs or come directly through the Salvation Army centre where the sessions are held.

John Devaney, a band 6 rotational specialist physio who runs the service, knows he will see most patients once only so the emphasis is on easily retained advice and education.

‘You need to keep it simple. If you are suggesting some exercises you need to make sure they can replicate them while they’re there.’ He also tries to highlight what might go wrong and suggests coping strategies.

An evaluation in 2014 showed those accessing the service appreciated the help they received. ‘Importantly, physios were sensitive and non-judgemental and patients felt they could trust them and work with them,’ says the study’s co-author Jane Hislop, physiotherapy lecturer at Edinburgh Napier University.

So why is more not being done? Dawes accepts that physiotherapy may be a lower priority for many homeless people than tackling a heart condition or addiction. ‘But who’s to say someone with an addiction problem isn’t self-medicating because of back pain and if you sorted that, the addiction might be easier to manage?’ 

Homeless healthcare charity Pathway wants  physios to be involved in managing many conditions experienced by homeless people, including MSK problems, amputee care, cardio, and pulmonary and neurological rehab. And it backs the creation of specialist physiotherapists for homeless and vulnerable people. 

‘Physios need to think about the challenges homeless people face and what they can do to make their services accessible to all,’ says Dawes. ‘We need to think about how we run services and how they might fit with a person who can’t fit around that. Are there simple things we can do to make it easier?’

This relates to a wider truth about tackling health inequalities, she adds. ‘It’s generally the people who need health care most who find it most difficult to access. But it’s not good enough to simply accept that and put the onus on those people to change their ways. Yes, it would be costly to put in place the services that meet their needs – but is that a reason not to do it?’.

Case study: walking to happiness

Walking may not at first sight seem the most obvious antidote to homeless people’s mental and physical health problems.

But a small-scale community walking group for people who were homeless in the Cardiff area, run by Cardiff University physiotherapy lecturer Rebecca Hemming, has brought a range of benefits, including companionship and improved physical and mental health.

The self-funded scheme, which ran from March to September 2017, involved a regular fortnightly walk of around 2-3 miles. An average of 4-5 people turned up for most walks which were supervised by qualified professionals or students.

The group, which was the subject of a small research study by Hemming and colleagues, went through a few changes along the way. ‘We learnt we couldn’t start the walks from anywhere except the homeless centre because people wouldn’t be able to get to the starting point,’ she recalls. ‘It was also important to start at the same time. Routine and consistency are absolutely key.’

They also learnt it was important to have refreshments. ‘Quite often the people might not have eaten so we brought water and fresh fruit and cereal bars.’

Probably the biggest benefit to participants was companionship and new relationships, says Hemming. ‘At first walkers interacted with us but not with each other. But towards the end they formed more of a group and started to share their experiences.’

Although the programme was only meant to last for six months, its popularity meant it continued and is now led by Cardiff University physiotherapy students. They also hope to hold physical activity classes (such as yoga) in due course.

The experience has been ‘an eye-opener, I’ve learned a lot,’ says Hemming. 

Author: Andrew Cole