The term ‘rough sleeper’ seems a derogatory one to me, yet I cannot seem to find an alternative. The language we use around marginalised people matters, because pejorative terms will only serve to stigmatise individuals, reinforcing stereotypes and making it even harder to address societal challenges that result in inequality. Official estimates of people who experience rough sleeping have increased by 165% since 2010 to 4677 (Public Health England (PHE), 2019). This does not count the ‘hidden homeless’—statistics for rough sleepers include people sleeping in cars or sheds but not those who are ‘sofa-surfers’, or living in squats, for example (Combined Homelessness and Information Network (CHAIN), 2019; PHE, 2019).
The causes and consequences of rough sleeping are complex and there are clear links with poor physical and mental health. Ill health can be a cause as well as a consequence of homelessness, yet may not always be identified as the trigger. Those who sleep and live on the streets experience some of the most severe health inequalities. Many will have poor mental health and will have often experienced significant trauma in their lives. PHE (2019) reports that half of those people living and sleeping on the streets will have mental health needs, 42% have alcohol misuse needs and 41% have drug misuse needs. There are a range of poorer health outcomes that the homeless person experiences, related to being exposed to poor living conditions, challenges in being able to maintain personal hygiene, a poor diet, high levels of stress, and dependence on drugs and alcohol. Of those people who were seen sleeping in the streets in London in 2017–2018, 46% had physical health needs (CHAIN, 2019). The prevalence of infectious diseases, such as tuberculosis, HIV and hepatitis C, is considerably higher in the street-sleeping population than in the general population. They are also at higher risk of musculoskeletal disorders and chronic pain, skin and foot problems, dental problems and respiratory illness.
Gaining access to primary care services is a major issue for many homeless people. They report being unable to register with a GP practice as they have no fixed address. It is a myth that the person must have an address or a form of identification in order to use GP services. NHS guidelines make clear that a homeless person has a right to register and can use all the services that a GP practice provides; furthermore, a person's immigration status does not affect registration (NHS website, 2019).
People who experience sleeping in our streets over a long period are more likely to die earlier, as well as facing a higher likelihood of dying from injury, poisoning or suicide. The average age at death of those who are homeless is 44 years for men and 42 years for women, versus 76 years and 81 years in the general population. Around 35% of people who die while sleeping rough will die as a result of alcohol or drug misuse. A third of deaths among people experiencing homelessness were due to conditions such as tuberculosis and gastric ulcers, which could be alleviated with timely and effective health care (Aldridge et al, 2019).
In offering care and support to homeless people nurses need to be able to provide care in a flexible way and in a variety of locations, bringing care provision to the people who need it. Care must reflect a holistic approach, responding to physical and mental health needs. It is imperative that the nurse understands and makes use of appropriate cross-service referrals (ie health services, housing and community and social support). Homelessness can be seen as a measure of our collective response to our fellow humans in need. Living and sleeping on the street is a social problem, not a criminal one.