People experiencing homelessness impeded from full access to health services, finds study

New research has found that populations experiencing homelessness find health services difficult to access and navigate. Findings suggest that a high degree of fragmentation in mainstream health services impedes full accessibility to treatment. The study, "How do health system factors (funding and performance) impact on access to health care for populations experiencing homelessness: a realist evaluation," is published in the International Journal for Equity in Health.

Short funding cycles and short term goals within the health service were found to add to this fragmentation. When mainstream health systems are unresponsive to the needs of populations experiencing homelessness, the research suggests they rely implicitly on specialized services, such as NGOs, to fill the gaps.

There's a large body of work that ascertains why these difficulties arise from the individual person accessing health care's point of view, but far less research has been done from the perspective of the health system, essentially exploring how health services are organized makes them difficult to access for severely socially excluded population groups.

The health system, including the Department of Health, the Health Service Executive (HSE) and NGOs, need to understand how they can possibly provide health services in different ways to this population and this research offers considerations for this provision.

People living in homelessness must try to fit into a system that is difficult to navigate. They have complex needs that require an integrated approach—which is not always available—and have often experienced significant trauma making them wary of people in positions of authority. Seeking health care can be difficult and uncomfortable.

Researchers interviewed 12 people working on the frontlines of health care services in Dublin, ranging from doctors and nurses to social workers and senior health care planners.

Key findings

1. A high degree of health service fragmentation is found when health systems are overly complex, both between and within services. As a result, services focus on prioritizing narrow, measurable goals and complex, specialist inclusion health needs must be provided for elsewhere.
2. Health systems prioritize meeting their own objectives such as limiting costs, focusing on bio-medical needs over social and mental health needs.
3. Patients are expected to fit in with the schedules, locations, and culture of the health system rather than understanding and addressing full patient needs.
4. Patients with complex must seek health services elsewhere (e.g. specialist homelessness NGOs), or they go without care altogether. When their care is effectively outsourced to responsive specialist practitioners and organizations, the health system as a whole is blind to their particular needs.
5. Health systems lack pertinent information needed for future, more adequate, service planning. Incomplete information is also fed into high-level policy decisions potentially leading to the de-prioritization of the needs of socially excluded populations.
6. As these needs are deprioritized, health systems continue to cater for organizational needs resulting in the maintenance of a fragmented health care system, and the cycle continues.

Dr. Rikke Siersbaek, research fellow and research lead, said, "Health systems must take responsibility for making health services accessible to everyone, especially those who face the greatest difficulties engaging with health care, such as people experiencing homelessness. Health services in Ireland are fragmented and often rely on individual practitioners with a particular interest in working with excluded people and independent NGOs to meet the health needs of socially excluded populations who often fall through the cracks of the mainstream health system."

Key recommendations

1. Develop a national strategy to guide integrated, coordinated health services to make the health system responsible for recognizing and responding to social determinants of health with adequate funding and specific goals attached.
2. Provide all practitioners and staff with adequate training and exposure to socially excluded populations to develop a baseline of knowledge and expertise in providing appropriate services to them, and provide expert training to specialist practitioners.
3. Develop and support trauma awareness and understand the role of trauma in homelessness, social exclusion, and health.
4. Embrace definitions of health that are not narrowly focused on bio-medical outcomes but holistically embraces all aspects of health depending on patient wishes at the time of a clinical encounter.
5. Adopt a flexible and inclusive culture championed by leadership at every level of the system.
6. Provide multi-year funding for health services.
7. Enable practitioners to organize services around the needs of patients by creating service structures and pathways with patient input, and through empowering practitioners to respond flexibly to the situations in which they provide care and need to act outside of the typical set of procedures.
8. Take responsibility for meeting the needs of all populations and put into place tools for gathering pertinent information for continual planning to adequately meeting changing needs on an ongoing basis.

Dr. Cliona NÍ Cheallaigh, associate professor, Department of Clinical Medicine, Trinity College, Inclusion Health Consultant doctor in St James's Hospital, and article author, said, "This study harnessed the experience and expertise of practitioners working in front-line services to develop a deep understanding of what we need to change in our health care system to ensure that everyone, no matter what their background, can get the health care they need."