Why Homeless Patients Still Struggle to See a GP

Great Chapel Street Medical Centre in central London is 1 of only 5 specialist homeless health surgeries in England. In the past year, the number of people seeking care there has risen by 30%. The centre is a one-stop shop for people who experience homelessness, many of whom are asylum seekers. The centre offers a wide range of healthcare services: a psychiatrist once a week, resident mental health nurses, specialist counselling, a podiatrist once a week, a weekly sexual health clinic, a legal adviser, and a specialist Roma clinic once a month — as well as everything a regular GP provides, but with more flexibility and time. "It's so important for people who are facing the biggest disadvantage in society and who have undergone traumatic journeys to have easy and holistic access to healthcare," a clinical lead at Great Chapel Street, Dr Dana Beale, told Medscape News UK. "But it is more expensive, and I wish there were more services. We will always argue that’s what we need to be equitable: to overreach to the people who need it the most." Rising Numbers, Falling Life Expectancy For the past decade, the number of homeless people across the UK has continued to increase. Today, 1 in every 45 Londoners is homeless, with the number across England reaching more than 380,000 people, according to the charity Shelter. "The situation is getting worse, it's terribly sad and quite honestly horrifying," Dr Kamila Hawthorne, emeritus professor at Swansea University and chair of Pathway, a homeless and inclusion health charity, told Medscape News UK. "A lot needs to be done." At least 1611 people died while homeless across the UK in 2024, marking a 9% increase from the previous year and the highest figure on record, according to the Museum of Homelessness's Dying Homeless Project. More than half of the deaths were classified as "deaths of despair" — primarily suicide and drug-related causes — which the charity described as "needless and preventable." The average lifespan in England and Wales for a homeless man is 45 years, and 43 years for women, compared to 78 and 82 years respectively, in the general population, according to the Office for National Statistics. They face complex chronic conditions at far greater rates than the general population. Research by the Pathway Partnership Programme found they are 34 times more likely to contract tuberculosis, 50 times more likely to have hepatitis C, six times more likely to have heart disease, and five times more likely to have a stroke. They also attend A&E six times more often than people with a home, are admitted to hospital four times as often and stay three times as long, and are less likely to be registered with a GP. The stark disparities raise questions: What could general practice be doing differently? What is working? What could be learned from best practices? Primary care for people experiencing homelessness is delivered through dedicated health centres, mainstream GP practices with special services for people who are homeless, general GP practices with no specialist services, and mobile outreach teams. Research has found specialist health centres and specialist GP sites to be the most effective models of care. However, the reality is that regular GPs are the main primary healthcare providers for many people who are homeless, especially those living outside of large cities, where specialised services are few and far between. "I think those who experience homelessness would go to a specialised service if they could. The problem is that the provision of homeless services is really patchy in the UK," Hawthorne said. "It requires resources — a multidisciplinary team that provides wraparound care and flexibility of appointments. But it really does make a big difference if you’ve even got a specialised GP within the practice — that’s been shown to work well, along with a completely specialist service for homeless people." Digital Barriers and Registration Hurdles Providing care to people experiencing homelessness is fraught with challenges. However, those interviewed said these could be tackled with more resources, a better understanding of the population's needs, and by fulfilling commitments in the 10 Year Health Plan for England to address what the plan calls an "intolerable injustice" in health inequalities. Paul Daly is the practice manager of Camden Health Improvement Practice, a multidisciplinary service providing primary healthcare to homeless people in Camden, London. For Daly, the greatest challenge is the digitalisation of healthcare — from online registration with a GP, to the push for online consultations and e-prescriptions — all of which, he said, only serve to exclude homeless people. "We've had a lot of pressure to register people online but then we'd never see them. It is ultimately not good for the patient. They won't mention they have a leg ulcer if someone is just writing a prescription on the phone," he told Medscape News UK. "We've given in a little bit and allowed people to register online but they must see us in person. However, I don't think one patient has even tried to register online. There's a big push with the NHS app but none of our patients will download an app — they don't have a smartphone. It's just insane." The practice instead registers people in person and uses the practice address to allow patients to receive mail, including other healthcare appointments and results. The 10 Year Health Plan for England states that the NHS will "create the most digitally accessible health system in the world," that will allow it to "become a fully digitally enabled service, operating 24/7 both online and offline." For Dr Natalie Miller, a clinical lead at Great Chapel Street, London, the move towards digital healthcare has benefits, but not for the population they serve. "The NHS app is only in English, it's a major barrier — it requires you to speak English, be literate, and have a smartphone. We're often looking at workarounds in the system, but more and more people are being pushed towards a system that doesn't meet the needs of the patients," she said. While NHS guidelines stipulate a patient does not need proof of address, ID, or an NHS number to register with a GP, the reality doesn't always reflect this. Dr Claire Rees, academic GP advanced fellow at Queen Mary University of London, who has worked in a homeless health practice, is calling for NHS England to change its registration guidance. She's trained dozens of general practice staff on the guidelines but has ultimately found that the message "wasn’t getting across, or viewed as particularly important." "I'm basically arguing that NHS England should change their guidance to say nobody should ask for proof of ID or address, because I think that's the only way that we can eliminate this problem. It is the major barrier to registering patients who are vulnerable, be that asylum seekers or homeless people," she told Medscape News UK. But the challenges extend beyond digital access. The clinicians also stressed that homeless patients needed flexible appointments, longer consultation times, and care free from stigma and discrimination. "For many surgeries, you have to call at 8 AM for an appointment or book weeks in advance, which is very difficult for people living on the street. This population is highly mobile, they're in survival mode, their health is not a priority," Miller said. "Mainstream primary care is designed to not allow time with patients to build engagement and rapport. Most people who are homeless have experienced significant trauma, which makes navigating systems extremely difficult." Rees added that another major challenge was funding. She recently lost her position as first clinical lead for homelessness in Waltham Forest, London, after funding cuts. "Funding does not reflect the complexity of the challenge," she said. "There are of course the practices that know their values and they're trying to treat vulnerable people and care about health inequalities. But if you've got a practice that is more financially motivated or is struggling, then that's going to be a barrier to them engaging with these patients unfortunately." What GP Practices Can Do Now Still, there are practical steps general practices can take now. One recommendation that came up repeatedly was for GP practices to sign up to the Safe Surgery scheme run by Doctors of the World UK, a nationwide initiative that helps practices commit to removing barriers to healthcare for migrants. Practices that sign up commit, at a minimum, to registering anyone without requiring proof of address or ID, and the scheme equips them with resources, training, and protocols to welcome migrants, asylum seekers, and those without housing. For Rees, this is not only about agreeing to register patients, but ensuring they have access to interpreters, and above all, ensuring that they feel safe at the practice by providing trauma-informed and stigma-free care. Hawthorne, who is a former chair of the Royal College of General Practitioners Council, said the college's Fairer Practice Toolkit is a valuable resource for supporting GPs and their teams in reducing health inequalities. The toolkit has more than 100 suggested actions across 18 themes and helps a practice to identify its “focus patient” group, such as people experiencing homelessness or those living in areas of high deprivation. Amid the digital push, she also encouraged practices which do see homeless patients to book appointments face-to-face. “It’s about the human touch, building trust, and offering continuity of care. In our rush to improve access to care, we’ve lost continuity of care — but there are all sorts of people who require more time and somebody to get to know them,” she added. Beale wants to remind people why the NHS was set up in the first place. “The NHS was set up for those who need it the most; to give people what they need, when they need it, to a sufficient level so they can live. But that often gets lost amid the political rhetoric,” she said. “We want to deliver the best healthcare we can to our patients, but when things are target driven, that’s where things fall down.” Contributors to this article reported no relevant financial conflicts of interest. Sophie Cousins, MIPH, is a global health journalist who has reported from more than 20 countries.