Homelessness

Introduction
Homeless people (1), travelling people and vulnerable migrants have an increased prevalence of both short- and long-term illness compared to the general population (2). Historically the NHS has considered vulnerable groups to be most at risk with regards to housing and social care issues, which are dealt with by other agencies. There is however increasing evidence to suggest that there are very serious discrepancies concerning health care.

Individuals from these vulnerable groups are less likely to access health care in the early stages of a disease or disability process and are thus more likely to attend A&E or be admitted to hospital as the result of serious acute disease or long-term chronic conditions. Reasons for limited access to health care include:
• inability to deal with bureaucracy
• lack of trust of organisations
• inability to register with a GP
• difficulty physically travelling to the point of care and the cost of travel
• inability to keep appointments as homeless people are less likely to receive a reminder (3)

Unmet health care need can of course lead to premature mortality, one staggering statistic being that the average age of death for homeless men in England is 48 years, and for homeless women 43 years (4); compared to 78 years for men and 83 years for women in the general population (5). Although increasing numbers of UK homeless people have access to GP services (94%) and dental services (91%), it is unknown how many have access to eye care.

There are many causes of homelessness and in most cases a combination of unresolved issues contribute to a person becoming homeless. Common reasons include:
• Relationship breakdown, which leads to homelessness for 41% of St Mungo’s clients (6)
• Financial problems
• Sexual or physical abuse
• Mental health issues
• Addiction
• Having an institutional background e.g. in care, the armed forces or prison

Types of homelessness
The common perception of a homeless person as a rough sleeper is inaccurate, as there is an increasing level of “Hidden Homeless”. Generally somebody is considered homeless if they lack a decent, secure and permanent home, so hostel dwellers, squatters, sofa hoppers etc. can all be classified as homeless.

“Statutory homelessness” occurs when local authorities define an individual or family as having a priority housing need, and that they are not intentionally homeless (7). Families with dependent children, pregnant women and adults assessed as vulnerable can all experience homelessness. Local authorities have a duty to offer accommodation to these individuals who can be considered priority cases.

Individuals and families who fall outside this definition are ineligible for priority, so tend to be supported by voluntary sector agencies. They include single people, couples or families with older children who are no longer dependent.

The number of “statutory homeless” households in England in 2013 was 53,540 (8), an increase of 35% since 2010. Official figures indicate that 2,414 people slept rough in England on any one night in 2013, an increase of 37% over two years (9). Local agencies have, however, reported that in London alone 6,437 people were seen rough sleeping in 2012/13 (10), an increase of 62% over two years.

Eye health needs of homeless people
Research in the US shows that homeless people have more eye problems than the general population (11). Problems include high prevalence of uncorrected refractive error, cataract, glaucoma and binocular vision problems (12). They are more exposed to risk factors such as poor nutrition, trauma, smoking, drug abuse and infections (13). There is a higher risk of macular degeneration as smoking rates are three times greater in the homeless population (14). General health conditions such as diabetes or hypertension, if left untreated and uncontrolled, can lead to sight loss.

There is limited peer reviewed published evidence regarding the ocular health of homeless people in the UK, however data from VCHP suggest that the UK situation is similar to the US. Homeless people have difficulty in accessing community-based optometric primary care, with 85% of homeless people preferring to access special homelessness services. VCHP figures show a greater percentage of eye injuries secondary to assaults than would be expected in the general population. The prescription range of patients seen in the VCHP clinics is from -20D to +17D, and without spectacles 35% of VCHP patients could be considered to have a functional visual impairment (15).

Availability of Eye Care
Historically some optometrists provided eye examinations in homeless centres on a domiciliary basis. In 2008 the NHS changed the regulations on domiciliary work, partly to reduce the risk of potential fraud. An Additional Service Contract (16) was created which requires contractors to specify that clients seen in domiciliary settings are unable to access an optometrist or optical service at a fixed location (i.e. Opticians) and that they have to be “persons who would have difficulty in obtaining sight test services by way of Mandatory Services because of physical or mental illness or disability or because of difficulties in communicating their health needs unaided”.

Furthermore, to satisfy the criteria of an Additional Service Contract a practitioner needs to give three weeks’ notice for seeing customers in this way (48 hours if 3 customers or less). This is a legitimate requirement for those providing services in Elderly Care Homes but problematic when applied to the highly transient homeless community and, as a result, domiciliary services in homeless centres have almost totally disappeared.

Effective primary eyecare services include delivering eye examinations, the provision of appropriate eyewear and the timely referral of those in need of secondary care. If someone is not eligible for GOS vouchers, then their only options are private eye care or charity. VCHP is a national charity established to provide eyecare services to homeless and other vulnerable people in an accessible and friendly environment in which they feel safe, welcome and comfortable. They have clinics in Birmingham, Brighton, Manchester and London. Their service includes screening of ocular health and provision of spectacles that meet immediate visual needs.

Optometry could also be part of an holistic approach to the complex combination of problems that homeless people experience. For example, VCHP clinics have established links with local GP services, so patients not currently registered with their GP can be seen at these surgeries. Most run drop-in clinics as homeless people often have problems keeping appointments.

Accessibility to eye care
Only 15% of homeless people receive state benefits, therefore most are not eligible for NHS sight tests. If they receive financial benefits they may be unaware that they are eligible for a NHS eye examination and a voucher towards spectacles. Even if they are aware, few practices provide spectacles free of charge and even a small charge may be unmanageable. Also, people are only eligible for one spectacle voucher every two years. Homeless people are more likely to have their property stolen, or be assaulted and therefore spectacles might be lost or broken beyond repair sooner than the two year interval.

Homeless people may feel uncomfortable entering a high-street optometrists, as they may not have an address to give. However according to the Child Poverty Action Group Handbook (17), homelessness does not exclude people from claiming benefits, as people can give a daycentre or other fixed address as a contact point, and this address could also be given at the optometrists.

Conclusions
Homeless people are very vulnerable (13) and are at one of the lowest points of their life where they simply cannot cope. One reason for this may be because they themselves have insufficient resource to cope with the stresses and demands of daily living. In other cases it is because of mental illness, family circumstance, alcohol or other addictions. They generally feel ignored by people e.g. they appear invisible in the street with people just walking past them. They need support through this challenging time of their lives but equally they may not be very trusting and can initially be defensive and refuse help when offered.

Homeless people face barriers to accessing health care but are more in need of eye care than the general population. There are lots of practitioners in the UK who have the necessary empathy and are keen to provide eye care services to this vulnerable group but the financial system and structure is currently not in place to make this possible. Access to eyecare services would detect avoidable sight loss and help people to maintain their ocular health.

There is a need for a national approach to the eye needs of homeless people through creation of new health care pathways, including referral to hospitals as necessary, as the current system is not working and charity provides limited provision. This would require changes to GOS regulations.

Further reading:

1. Physical diseases among homeless people: gender differences and comparisons with the general population. National Centre for Biotechnology Information 2009

2. Hidden Needs – Identifying Key Vulnerable Groups in Data Collections: Vulnerable Migrants, Gipsies and Travellers, Homeless People and Sex Workers. Peter J Aspinall, Centre for Health Services Studies, University of Kent 2014 Inclusion Health

3. Promoting the health of homeless people. Setting a research agenda. Health Education Authority 1999

4. Homelessness kills: An analysis of the mortality of homeless people in early twenty-first century England. Crisis 2012

5. Longevity science advisory panel. Life expectancy: Past and future variations by gender in England & Wales. LAP paper 2. Longevity Panel 2012

6. Home is where the heart is. Homelessness and rebuilding relationships. St Mungo’s and Relate 2007

7. Homelessness Code of Guidance for Local Authorities – Department of Health Department for Communities and Local Government 2006

8. Department for communities and local government. Statutory Homelessness: January to March 2013 and 2012/13, England. Department for Communities and Local Government 2013

9. Rough Sleeping Statistics England – Autumn 2013 Official Statistics. Department for Communities and Local Government 2014

10. Street to home bulletin 2012/13. Combined Homelessness and Information Network (CHAIN) 2013

11. Gelberg L, Andersen RM, Leake BD. (2000) Healthcare Access and Utilization. The Behavioral Model for Vulnerable Populations: Application to Medical Care Use and Outcomes for Homeless People Health Service Research 34, 1273-1302. National Centre for Biotechnology Information 2000

12. Shahid K, Kolomeyer AM, Nayak NV, Salameh N, Pelaez G, Khouri AS, Eck TT, Szirth B. (2012) Ocular telehealth screenings in an urban community. Telemed J E Health. 18:95-100. National Centre for Biotechnology Information 2012

13. LSE Manheim Centre for Criminology Living in Fear: Violence and Victimisation in the Lives of Single Homeless People Crisis 2004

14. Tobacco Use and Homelessness National Coalition for the Homeless 2009

15. International Classification of Diseases (ICD) World Health Organisation 2010

16. General Ophthalmic Services Contract Association of Optometrists 2008

17. Welfare Benefits and Tax Credits Handbook Child Poverty Action Group 2014