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Where do the homeless figure in health reform?

We’ve heard a lot of debate about what proposed health reforms might mean for people with chronic diseases or people on hospital waiting lists.

But we haven’t heard much at all about what the reforms might mean for one extremely needy group who are often not well served by existing health services or funding structures.

Professor Ian Webster, a longstanding advocate for the homeless, has some suggestions for those driving health reform about what they need to consider if they want to better address the needs of the homeless.

He writes:

“The fact of homelessness is a test of our social and health policies. Between 2001 and 2006 homelessness increased by 17% with 16,000 in Sydney and 14,500 in Melbourne on the census night.

The health reforms currently proposed by the Commonwealth will aim to get primary health care (PHC) into disadvantaged communities and better management for complex health problems. Homeless people are one such community. In parallel with these reforms, the National Mental Health Plan has put social inclusion at the top of its priorities as it recognises the high risk of mental illness in homeless people.

The White Paper, The Road Home: A National Approach to Reducing Homelessness says ‘no person need be homeless’. It aims to ‘turn off the tap’ and prevent homelessness and proposes there should be ‘no wrong doors’.

In other words a person should be picked up at any point between the initial crisis and long-term homelessness.

This is a long way from the Homeless Persons Assistance Act of 1974 introduced by Bill Hayden to assist non-government organisations to provide shelter. Up to that time homeless policy was no policy; that was the job of the churches and charities. That 1974 Act and its iterations have never addressed health needs.

A street clinic in New York found that a homeless person had an average of 9 concurrent medical conditions.   It is the same in Australia: 75% of homeless people in Sydney in 1998 had one or more mental disorders – schizophrenia in 23% of men and 46% of women and an alcohol disorder in 49% of men and 15% of women. Every second person was physically unwell.

To do anything worthwhile for homeless people, a health service must be where the homeless are, in the environment of the homeless, free at the point of delivery and able to respond to multiple needs. Only in this way will there be a doorway into mental health services. The homeless need safe places especially when they are ill as do homeless families as the children have high rates of serious health and psychological problems.

Homeless women have special needs for contraceptive and pregnancy management and need treatment following physical and sexual violence. And for young homeless people a special style of service is the only way to engage with them.

People with mental disorders fall out of the service systems and are inadequately followed up. This is especially true of homeless people. They need assertive follow-up to overcome their reticence and embarrassment of their marginal status. Thus front-line services should be based on ‘open door’ and ‘no wrong door’ principles.

The main funding mechanisms in general practice – the Medicare item-for-service schedule and the Pharmaceutical Benefits Scheme – do not fit this population’s characteristics of transience, loss of identifying papers, intermittent contact and high prevalence of chronic and relapsing diseases such as diabetes, chronic lung disease and especially mental illness and substance use problems.

It is at times an insurmountable task to arrange psychiatric medications, antibiotics, addiction treatment, chronic pain management and even such straight forward measures as wound dressing, for these people.

A new kind of primary healthcare and general practice will need to be constructed if a dent is to be made in the increasing numbers of mentally ill homeless people. Will the proposed health reforms do this?

• Ian Webster is Emeritus Professor of Public Health and Community Medicine at the University of New South Wales and Consultant Physician.

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