Rough sleeping can be defined as ‘sleeping outside or in places that aren't designed for people to live in, including cars, doorways and abandoned buildings’ (Crisis, 2024). However, government guidance suggests that, when counting the number of people sleeping rough in an area, the following definition should be adopted:
‘People sleeping, about to bed down (sitting on/in or standing next to their bedding) or actually bedded down in the open air (such as on the streets, in tents, doorways, parks, bus shelters or encampments). People in buildings or other places not designed for habitation (such as stairwells, barns, sheds, car parks, cars, derelict boats, stations, or “bashes”).’
Department for Communities and Local Government (Gov.uk, 2010)
Statistic for the UK show that, in 2023, 2893 people were sleeping rough on the streets of England on a single night in June (Gov.uk, 2023a), in Wales 169 were sleeping rough on a single night in October (Welsh Government, 2023), and in Scotland 1500 households were sleeping rough on a single night in August (Scottish Government, 2023). The London-only Combined Homelessness and Information Network (2024) estimated that in the English capital alone 10 053 people slept rough between April 2022 and March 2023. Although the collection of data across the UK varies from point prevalence snapshots on certain nights over the year to reports of applications for housing support, it is apparent is that the numbers of people sleeping rough are rising (Wilson and Barton, 2022).
In England, the average age of a rough sleeper is 26 years; men outnumber women in a ratio of 6:1 and all can experience both physical and mental health problems (Gov.uk, 2023b). Skin disorders, soft tissue infections and wounds are common health problems in people who sleep rough (Wright et al, 2020) and access to healthcare services varies owing to issues around trust, problems navigating services and perceptions about rough sleepers from staff.
As a group of individuals that are hard to reach because of their chaotic lifestyles and complex needs, rough sleepers are less likely to engage with supportive services such as district nursing services (Parr, 2019).
Types of wounds in rough sleepers
The types of wounds that homeless people sustain can vary from acute wounds such as burns, infected injection sites, abscesses and cellulitis to chronic wounds such as leg ulcers and pressure ulcers (Thomas, 2019). Homeless and vulnerable adults have a high prevalence of lower limb wounds. The types of wounds that present vary and develop for multiple reasons.
The most common types of wounds that homeless and rough sleepers present with are skin and soft tissue infections (Wright et al, 2020). These are more common in people who inject drugs via either subcutaneous or intramuscular routes. Drug users will use the same injection site repeatedly to access the femoral vein until a successful injection is achieved (Coull and Sharp, 2018). This will increase the user's risk of common skin and soft tissue infections such as abscesses, cellulitis and venous lower leg ulceration developing (Coull et al, 2021), which can lead to more severe complications such as endocarditis, deep vein thrombosis, sepsis and even death (Wright et al, 2020).
Venous leg ulcers are also prevalent within this group because of the damage that is caused to the arteries and veins through continuous, multiple injections within the same area of skin, which cause scarring and narrowing of the lumen (Doran et al, 2022). This can disrupt the venous return from the lower limb, causing the backflow of blood and lymph fluid, which in turn causes small breaks in the skin that then evolve into venous leg ulceration (Pieper, 2019).
Rough sleepers are also prone to the development of pressure-related skin injuries (Porter-O'Grady 2021). Pressure ulcers are defined as a break in the skin, which can be superficial in depth, which can evolve into deeper areas of ulceration where bone, tendon and fascia may be exposed (European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance, 2019). The development of pressure ulcers can be multifactorial, but common causative factors in those who sleep rough include a lack of adequate bedding, poor footwear and a poor diet (as good nutrition is required to maintain normal skin function) (Moor, 2019).
People who sleep rough can experience extreme weather-related injuries, such as sunburn, windburn, frostbite and trench foot (Thomas, 2019). They can also be prone to common foot injuries developing because of ill-fitting footwear, which include tinea pedis, foot pain and functional limitations (To et al, 2016). Foot problems in this group can be exacerbated in those who have diabetes, as these injuries can cause diabetic foot ulceration and nail pathologies (To et al, 2016).
Wound care initiatives for rough sleepers
Across England, initiatives have been developed to improve access to wound care services for those who sleep rough. The National Wound Care Strategy Programme (2024) provides a virtual platform to share some of these initiatives, ensuring opportunities to learn about inclusive practices for those most underserved by the NHS. The National Institute of Health and Care Excellence (NICE) (2022) and Public Health England (PHE) (Gov.uk, 2021) also provided guidance to clinicians and providers of services to the homeless and those who inject drugs.
Wound care for homeless people
Emergency departments (EDs) are often the pathways into health care for those who sleep rough. This is because traditional health and care systems often fail to meet their needs for a multitude of reasons, including poor experiences or prejudice, or because rough sleepers feel being embarrassed by their condition. ED admissions also fail to achieve long-term management of this client group and a revolving door approach occurs that includes, at times, discharge to the streets (Malik and Geraghty, 2021).
Fulfilling Lives in Islington and Camden and Camden Health Improvement Practice collaborated on two projects in 2019 and 2020, one of which was a nurse-led, specialist wound clinic for people experiencing homelessness in London. The specialist clinic ran for 2 days a week for 8 months to pilot a comprehensive lower limb service for people experiencing homelessness, who were at risk of or living with an open wound or leg ulcer. The results of the clinic included the delivery of 113 patient reviews, 13 hours of telephone advice and three educational study days (Malik and Geraghty, 2021).
Wound aware: a resource for commissioners and providers of drug services
In 2021, PHE (Gov.uk, 2021) published a resource for commissioners and providers of drug services. The Wound Aware document highlights the life-threatening wounds and complications that can occur when people inject drugs. The document also provides guidance and support so services can be become more wound aware and identify wounds earlier on, highlighting the risks and signs of wounds among people who inject drugs and interventions to reduce the risk of harm from wound infections. The guidance also explores barriers to treatment and provides example case studies, links to resources and information for service users on safer practices.
Integrated health and social care for people experiencing homelessness
In March 2022, NICE published guidance to assist in the provision of integrated health and social care services for people experiencing homelessness. The aim of this was to improve access to and engagement with health and social care, with care co-ordinated across services. The guidelines provide recommendations on many aspects of care from planning and commissioning, models of delivery and improving access to services. The committee that wrote the document also called for further research in this area of care provision (NICE, 2022).
Case study
This case study examines the care of a long-term homeless man who presented with a lower limb wound at a district nursing clinic.
Jim Smith (not his real name) is a 63-year-old man who has been classed as homeless for more than 30 years. He is unable to determine exactly his time without a place that society classes as home because his memory and interest in dates are minimal. In his younger years, he had always been—in his words—‘a rum ’un’. He did not do well at school and was easily distracted, finding it difficult to concentrate on reading and writing, feeling that the ‘words moved around the page’. He left school aged 14 years and started to hang about with a local gang who were involved in petty crime, car theft and intimidation. He bounced between young offenders' units and sofa surfing. His family felt his behaviour was detrimental to his younger siblings, and police and social worker intervention caused them concern.
During his formative years, Mr Smith was introduced to class A drugs and alcohol, something he explains he used to numb the pain of feeling neglected and worthless. As his drug and alcohol addiction increased, he found his need for money rose too. This resulted in him needing to find ways to make money; this started a spiral of increased drug and alcohol use, and petty crime, which led to increasingly more serious crimes. A cycle of incarceration, substance misuse, rehabilitation and probationary services then began, and he developed a distrust of authority figures.
Mr Smith presented at a community nurse clinic without an appointment; he asked to see the nurse so they could take a look at his leg. At an initial assessment, it was noted that he weighed 39.6 kg and his MUST (British Association for Parenteral and Enteral Nutrition, 2003) score was 2. He reported that he had not eaten for 2 days because he had been unable to go to his usual support in the city centre as he had no money for transport. He normally walked 6 miles into the city centre; however, his leg was painful. From his presentation, his clothes are soiled with food, vomit, alcohol and general detritus. There was a compression bandage on his left lower leg had, which was soiled with urine, general debris and exudate. On removal of the dressing, it was noticed that the compression had been pushed down to his mid-calf in a clumsy attempt at re-establishing its position. There were fresh injection sites to his calf, with multiple wounds to his lateral lower leg, the largest measuring 7 cm x 6 cm, with 100% slough, macerated outer edges and local signs of infection.
A swab of the wound was taken, following which the wound was cleaned and redressed. This interaction also allowed for time to talk to Mr Smith about health promotion and having a good meal from one of the soup kitchen providers. He was also asked where he would be sleeping that night, and whether he would consider a hostel placement until he felt better. This enabled an opportunity to signpost him to the homeless support team.
He replied with a wry smile: ‘Miss, you know I won't go to a hostel. Can I have some dressings to take with me? I will be OK.’ The nurses tried to arrange a follow-up appointment and write this information down on a card while reminding him that he must come on this date at this time. He nodded, thanked the nurses, walked out of the clinic and everyone knew it might be 2 weeks before he would be seen again.
Conclusion
Nurses play an important role in ensuring that adults who sleep rough have access to care and management of their wounds. Competence in managing care delivery for patients from this group includes the promotion of trust, non-discriminatory practice and a flexible clinical approach necessary to connect with the client and those supporting them.
Common wounds that develop in rough sleepers vary and include burns, infected injection sites, abscesses, cellulitis, leg ulcers and pressure ulcers.
Innovative practices in the creation and delivery of services and clinical guidelines have been developed to ensure efficient and safe care. Although most wounds can be managed by community services, some can require urgent medical assistance because of their severity.
KEY POINTS
- Adults who sleep rough are at risk of developing wounds and skin and soft tissue infections
- Innovative service provision is required to meet the needs of this underserved population
- Compassion, empathy and a flexible clinical approach are necessary when caring for people who are homeless
CPD reflective questions
- What type of wound do you think Mr Smith would be diagnosed with, and what treatments might be prescribed?
- What are the issues with reapplying compression to his legs?
- What health promotion advice might you give to Mr Smith in the care of his wounds?