COVID-19 homelessness and care

While many groups: elderly people (Chen et al. 2021), communities of colour and people with disabilities (Abrams and Szefler 2020; Dovie, Mariela, and Magdalena 2020) were hit especially hard by the pandemic (and the effects of lockdowns, in particular) forcing many to lose their jobs and potentially their homes, people experiencing homelessness experienced a silver lining during COVID-19 in the form of UK government funding (Ian Hamilton: Covid-19—Are We Rationing Who We Care about? - The BMJ). Financed mostly by the Treasury (“£105 Million to Keep Rough Sleepers Safe and off the Streets during Coronavirus Pandemic - GOV.UK.”) under an extension of the ‘Homelessness Initiative’ of 2018, the scheme entitled ‘Everyone in’ (Crisis 2020), was focused on providing emergency accommodation during the lockdown as well as the promise to create 3300 move on homes by the end of March 2021 (COVID-19: Housing People Sleeping Rough - Public Accounts Committee - House of Commons).

While effective for some—with 37 000 people given emergency accommodation (‘Everyone In” Scheme Exposed Gaps in Government, Crisis UK)—the needs of some groups, particularly those requiring specialist healthcare services, continued to be overlooked (Homeless Migrants Still Sleeping Rough despite PM’s Pledge). Based on almost 1 year of ethnographic fieldwork and interviews, performed by the three authors in joint and individual projects in a UK university town, in this paper, we focus on two particular kinds of exclusion. Abstracting from observations from a multitude of support institutions for people experiencing homelessness (emergency housing/assessment centre, Covid-specific hotel, healthcare providers), we illuminate both the exclusion of people experiencing homelessness with complex needs and problems surrounding digital support, specifically for women in situations of homelessness. While these exclusions are not new or caused by COVID-19 and the surrounding lockdown measures, the measures made the exclusion of some people particularly visible. On the one hand, additional rules (eg, during lockdown) led to the exclusion to specific groups (eg, people with complex needs) to protect the majority, for example, in a Covid-hotel; on the other hand, shifting service provision (from inperson to online) also affected certain groups (eg, women experiencing homelessness). All of this happened despite additional funding available—which itself still had a positive impact for many people experiencing homelessness. We believe our observations show issues on a systemic level with the care provision for people experiencing homelessness which has—over years—become atomised and disadvantaged people who are already more marginalised. Consequently, in the final section of the paper, we propose several (counter) measures to set up a more inclusive system of care provisions.

Multiple exclusions: substance use, complex needs and digital shortcomings

As care provision for people experiencing homelessness, including healthcare, has become increasingly more specialised, it has been divided into individual systems rather than focused on providing a holistic approach. For the general population, care similarly often has become disjointed and uncoordinated with each patient seeing several doctors to provide adequate care for one condition. For people experiencing homelessness, the support they are (often) dependent on has been further under pressure. Generally, driven by de-institutionalisation and a push for community care as early as the 1970s in the UK (Baldwin 1993; Craig and Timms 2009) and more recently austerity measures and welfare reforms, service provision has become reduced and fragmented for people experiencing homelessness (Cameron et al. 2016; Gunner et al. 2019). In the local set-up where our research studies took place, we observed this development acutely already pre-COVID-19: different parts of support and care provision for people experiencing homelessness were distributed both geographically and institutionally. Specialist, individual service providers were respectively responsible for the provision of housing, benefits, education/training, substance use (including support groups), drug testing, mental health support (if available at all) and physical health. Any individual person experiencing homelessness and struggling with a variety of issues would be tasked to interact with as many different service providers as that person was encountering problems . In few cases, support workers (eg, at the place of housing provision) were tasked with and able to provide coordination and continuity of care. In fact, the commissioning of the different pieces of the support network was done by different parts of the local councils, to begin with (drug use, housing, healthcare—generally all treated separately) going back to individual budgets (per issue area). As a result, people experiencing homelessness in general were—driven by large institutional changes over decades—forced to operate a multistakeholder, specialised and fragmented service provision system; in our specific empirical context, they were only occasionally supported and accompanied through the entirety of this system by a specific support worker. Additionally, we observed a lack of institutionalised coordination and even communication (eg, supported by a single software system) by the support providers making the desired continuity of care and support (Jego et al. 2016; Lamanna et al. 2018) complicated if not impossible and leaving many people experiencing homelessness without access to the care they needed.

For people experiencing homelessness and struggling with complex needs, navigating a fragmented healthcare system is even more challenging. The National Institute for Health and Care Excellence (NICE) defines people with ‘complex needs’ as ‘people needing a high level of support with many aspects of their daily life and relying on a range of health and social care services’ either because of ‘illness, disability, broader life circumstances or a combination of these’ (Guideline Scope Adults with Complex Needs: Social Work Interventions Including Assessment, Care Management and Support). So not only do people with complex needs have more support needs (eg, housing as well as mental health and substance use support), they also struggle more likely with navigating everyday administrative tasks (Viertiö et al. 2012; Dewa, Thompson, and Jacobs 2011). Overall, it is well established that individuals experiencing homelessness are at a greater risk of negative health and social outcomes, with an average life expectancy of 45 years for men and 43 years for women (30–40 years less than the UK national average) (Deaths of Homeless People in England and Wales - Office for National Statistics). Unsurprisingly, numerous studies have highlighted disproportionate levels of cardiac problems, long-standing tuberculosis, hepatitis C compared with age-matched housed individuals (Aldridge et al. 2018). This trend is also seen in mental health: a recent study by Groundswell found that 64% of homeless women questioned were experiencing mental health problems compared with 21% within the general population (About Groundswell 2020).

People experiencing homelessness and struggling with specific and often complex needs often require support from multiple specialists to manage their care; many of these individuals would also need additional support from a care coordinator to oversee appointments and advocate for their needs.However, currently, there is very little research into how to best support people with complex care needs (Fortin et al. 2005; Fortin et al. 2007) leaving many people to fall between the cracks (Coleman 2003) of support. It was only in October 2021 that NICE compiled its first-ever draft guideline for the ‘Integrated health and care for people experiencing homelessness’ (NICE 2021); so far, many clinicians are unaware of this new guidance and do not use it routinely in their clinical practice. Although a handful of specialist homeless mental health services do exist, most have been disbanded due to lack of funding (St Mungo’s 2011).

While this exclusion is partly driven by the fragmented set-up of the support provision system, an additional factor is discrimination (Homeless People Are Among the Most Vulnerable to the Coronavirus. Yale Psychiatry’s Lo Is Making Sure They Still Receive Care Amid the Pandemic. < Yale School of Medicine), and yet another factor is strict exclusion criteria for certain services, for example, around the so-called condition of being housing- or treatment-ready (Padgett et al. 2010; Padgett, Henwood, and Tsemberis 2015). As a result, an additional burden falls hardest on those with complex needs or dual diagnosis (concurrent mental health problems and substance use) (Schütz et al. 2019), where (despite regulation changes) these individuals are continuously sent from service to service as they do not meet the ‘treatment-ready’ requirements for substance use or stable mental health, (St Mungo’s 2011).

With the onset of COVID-19, the already atomised and hard-to-access resources were further stretched and access made complicated (Shock to the System: COVID-19’s Long-Term Impact on the NHS - The Health Foundation; Aburto et al. 2021; Propper, Isabel Stockton, and Stoye). In the empirical context of our research studies, we observed how service provision for people experiencing homelessness were either reduced in scope (eg, fewer beds offered to adhere to social distancing, certain services (like drug testing) suspended for the same reasons) or altogether (temporarily) suspended (eg, drug and substance use support groups were suspended for several months during the first lockdown in our local context). Additionally, given the lack of overall specific government instructions for homeless support institutions at the beginning of the lockdowns, guidelines had to be made up on the spot (eg, by the management of service providers) and were often changing and unclear; eventually, these guidelines became stricter as we explain below, particularly impacting people with specific support needs to protect what was perceived to be the (more compliant) majority of people. Individuals experiencing homelessness were on the one hand supported more, particularly with housing, with additional government funding being made available. On the other hand, however, specialised support (eg, for people with complex needs or dual diagnosis) was even harder to access. This was also not alleviated for certain groups (eg, women) with a (experimental) shift to digital platforms as we will show further down below. With a lack of suitable technology and inadequate training many of these individuals were and continue to be unable to access even basic (health) services—often both digitally and inperson—which increases their reliance on underfunded but trusted non-profit organisations to fill in the gaps.

Addiction hurts, at least twice, during COVID

Ben really isn’t keeping up well. He looks fine, but he’s been complaining and he’s constantly out. […] You don’t see a change with everyone, but with him […] it’s so obvious. He is back on the crack, too. And he was supposed to move out soon – but at the moment nobody is moving. They are all staying longer than the 28 days [the supposed length of an average stay at the assessment centre].

Dannie explained to me (JL) who Ben was while we were standing behind the kitchen counter during an evening which I spent volunteering at a short-term hostel (the Centre) in a UK university town in April 2020. Dannie was a long-term volunteer and familiar with many of the people circling through the centre and my partner on that particular evening. Ben was obviously not doing very well; he was zigzagging through the room towards the counter we stood behind, trying not to fall. Dannie and I were responsible for serving the dinner—one of the tasks for the two evening volunteers—and Ben had come to get his. While COVID-19 restrictions, such as social distancing, were taken very seriously in the Centre, there wasn’t enough space for that during dinner. As a result, residents were sitting on the couches; a loud action movie was running on the television. When Ben arrived at the counter, we both smiled at him: ‘Do you also want dinner? Any special requests?’. Looking up briefly, Ben’s teeth were moving and he fumbled around with his hands in his pockets; he wasn’t able to stand still. Mumbling a short ‘No’, he quickly grabbed his plate and disappeared within minutes, having gulped down his dinner.

At the beginning of the full restrictions of the first COVID-19-related lockdown in the UK, homeless service providers were facing their limits and so were the people depending on their support and care. In a Harvard Health post from 2020, a US-front-line doctor (and recovered opiate user) contextualises the double hit we observed also in the UK (A Tale of Two Epidemics: When COVID-19 and Opioid Addiction Collide - Harvard Health). Reporting on what he calls the ‘two great epidemics of our generation’, he argues that people suffering from substance use on the one hand ‘are vastly more vulnerable to coronavirus’; on the other hand, they also suffer from shortages of supplies (of methadone and other medications, for instance, at times even clean needles) and of increased issues of isolation, specifically when it comes to the lack of access to their recovery community and peer-support groups that were so often suspended during the pandemic lockdowns.

In the UK context, we observed both of these issues hitting people like Ben hard, too. Ben was young, reasonably healthy and very much used to accessing his friendship group—some of whom were not experiencing homelessness—outside the Centre most hours of most days before the pandemic and its restrictions. His friendship group also doubled as his circle of drug buddies, people Ben would consume drugs with every day, as well as pool money with to buy supplies more cheaply. While his drug use—as he explained in an interview later, of crack and cocaine—continued before the pandemic, Ben was seen as doing reasonably well; he was on track to access longer-term housing, as one of the assessment centre’s managers explained in a later conversation. During the first lockdown, as institutions such as the Centre were experimenting with how to best protect their community, leaving the Centre was not permitted, apart from for specific (mostly medical and ‘exercise-related’) reasons. As a result, Ben was not regularly allowed to go out and hence not able to access the community he usually relied on (‘I rely a lot on my community […] experienced a lot of community through prison’, he explained in an interview with JL in summer 2020). While he breached this rule for a while on an almost daily basis (and was initially not sanctioned), his drug use was rapidly increasing; Ben called it ‘a sort of non-stop relapse’ in the interview with JL, including smoking crack in the assessment centre (‘one of the times the fire alarm went off’). Difficulties with accessing drug supplies (drug dealers weren’t out as frequently and buyers had to travel farther) made his drug use more complicated and forced him to go outside frequently and for long stretches of time, against the rules eventually installed and enforced by the Centre. Given an explanation from one of the support workers familiar with Ben (and the recorded history this support worker mentioned), we can assume that he was additionally struggling with mental health issues, such as anxiety and depression (while he did not mention those in the interview with us). A vicious circle was pushing Ben to the point where JL first encountered him (see initial vignette above).

Even though staff and volunteers at the Centre noticed the increased support needs for Ben and others (as our interviews showed explicitly), there was very little specific support they could offer, particularly during the first lockdown in spring/summer 2020. Ben, for instance, had relied on regular inhouse drug testing to keep himself accountable (‘to rebuild (his) life’, as he explained); that support stopped to adhere to social distancing and as a precaution to keep staff safe. Internally, a major concern was to protect staff (from COVID-19 infections) in the different institutions we observed to keep a minimum of operations functional. Already before the pandemic, the vast majority of specialised mental health and substance use support services had been outsourced systematically to specific service providers; the local substance use support service stopped providing any support during the first lockdown and switched to phone support eventually after a several-months long suspension.

At the Centre, one way of coping with the increased support need and burden was to experiment with changing rules. While COVID-19-related lockdown rules (as mandated in other institutional contexts by the UK government) were introduced, other rules were relaxed. One of the Centre managers, John, explained how balancing residents’ needs and the responsibility to protect staff (and the functioning of the Centre as a whole) was complicated but something they attempted by granting residents certain liberties inhouse. While the Centre—like most service providers—was a ‘dry Covid-hotel’, that is, no alcohol (or other substances) was allowed on-site, a specific area downstairs was opened up for the consumption of certain (weak, up to 5% vol) alcohol during the first lockdown in April 2020. This rule was further relaxed—removing any restrictions on the type of alcohol allowed—several weeks into the lockdown. But people’s rooms were out of bounds, still. John reflected: ‘How are we supposed to keep that [being a dry Covid-hotel] up when people aren’t allowed to leave? They aren’t even allowed to sit in the park. […] Many of our residents have a substance use problems. […] That’s the least I can do. We even buy it for people if they are self-isolating and ask us to. […] One of our biggest problems is keeping people inside, behavioural issues, really’. While for many residents—in the Centre and many other homeless institutions—relaxing restrictions around alcohol consumption were tremendously helpful in a time of stress and crisis, as the case of Ben above shows other substances were even more complicated to manage.

While restrictions around consuming ‘hard drugs’ were impossible to relax legally, Centre staff showed a certain kind of lenience with Ben and others initially. Another staff member, Ollie, explained to JL in an interview: ‘I know from personal experience, if you are in (drug or alcohol) withdrawal, nothing will stop you going out to get your substance; coronavirus won’t even cross your mind’. Ollie was sympathetic with the struggle of people like Ben, but also wary of handing over a blank check to people who use drugs in a situation of crisis: ‘If you turn a blind eye to it: drug-dealing, drug-sharing, violence, reliance on each other – it’s a whole different culture!’. The staff seemed to be united in being unable to alleviate Ben’s particular struggle—fearing the situation could slide completely out of control. Setting a wrong precedent was deemed even more dangerous than supporting people—in whatever way or form was possible—under exceptional circumstances.

Over time, with lockdown restrictions staying in place for months, management at the Centre was increasingly overwhelmed; while Ben’s problems were significant, others were struggling, too. More and more staff were self-isolating, putting additional pressure on the remaining members of the team. Managing the day-to-day operations became a stretch, to begin with, and the team overall managed incredibly well (there was not a single case of COVID-19 reported among residents in the assessment centre in 2020). Dealing with people who had increased support needs was putting a lot of pressure on the functioning of the institution as a whole. The immediate goal for management was to enable all residents to be as supported as possible; they were facing a trade-off as Ben and others would not stop excursions outside and put all people in danger (of ‘importing’ COVID-19 into the Centre). Ben himself reflected that he was surprised to be ‘let loose’ for so long: ‘(I had) so many final warnings. […] they let us go four or five (hours) […] then they finally cracked down’. Faced with a decision to be lenient with some or keeping the majority of the Centre (and its staff) as secure as possible, management ultimately decided to stay on the side of more solid enforcement of rules and structure. Over the course of several weeks in late spring 2020, not only Ben but several other people—most of them struggling with complex needs between mental health and substance use—were evicted (or as I was told: ‘asked to leave’) from the Centre after receiving at least two warnings but continued to breach the ‘stay at home’ order.

At the Centre in the UK university town where we conducted a significant portion of our research, but also in many other homeless service institutions, emergency shelters and temporary ‘COVID-19 hotels’ in the UK, Europe and the USA (Homeless People Are Among the Most Vulnerable to the Coronavirus. Yale Psychiatry’s Lo Is Making Sure They Still Receive Care Amid the Pandemic. < Yale School of Medicine; Homeless in Europe the impact of COVID-19 on Homeless people and services contents) the people who were hit most by COVID-19 and the reactions to it were among the most marginalised and in need. Given that most specialised support—particularly for people who use drugs and/or struggle with mental health issues—has historically become outsourced to specific service providers (including general practitioners (GPs)), restrictions of the free movement of people hit those particularly hard who were dependent on accessing a larger variety of different support providers. Many were not able to access any support for their often ever-increasing support needs during the pandemic. Even when some support shifted online or to the telephone (often until today, see below), people with complex needs continued to struggle to engage. COVID-19 (and the restrictions around it) hit people with complex needs at least twice: while stress levels and mental health needs increased (eg, due to isolation, fear of catching COVID-19, no ability to meet friends, new behavioural rules (particularly during periods of lockdown), self-medication with drugs was made more complicated. Not only was supply harder to come by on the street (and so was money from begging, often needed as supplementary income), people in places like the Centre were also simply not supposed to be outside, a rule that was increasingly enforced. Lockdown not only disrupted normal routines, but it also quasi-criminalised some of the routine behaviours our informants’ well-being depended on, either by government-imposed or institutional rules (eg, ‘hanging out’ with friends outside). As a result of the ‘misbehaviour’ and ‘disobedience’, some residents like Ben were eventually evicted from the support institutions, to protect ‘the majority inside’. As a final result, being back on the street, left people (at least temporarily) even further marginalised from healthcare support (beyond street outreach which laudably was in operation throughout most of the lockdowns).

Digital care? talk of the future…

From the outset, a shift to digital consultations promises to change the landscape of healthcare access to the better, also for people experiencing homelessness.

People no longer need to travel to appointments or leave their places of residence or comfort (eg, a day centre); digital technology allows them to access healthcare services from anywhere with the right mobile device and sufficient signal (You Mean I Don’t Have to Show Up? The Promise of Telemedicine - The New York Times).

While the use of video consultations in healthcare has steadily been increasing for a number of years (Car et al. 2020), it was with the start of the COVID-19 pandemic that we have seen another sudden shift to remote consultation, in some settings completely replacing any face-to-face interaction. To protect both patients and doctors, inperson consultations were reduced to a minimum across the UK’s healthcare system already during the first lockdown. Telephone triage became the new normal and doctors and patients alike were forced to learn to adapt to new methods of communication, including specific applications (eg, accuRx (General Practice)).

Although mobile phone use and texting are very common among people experiencing homelessness (with between 89% and 94% of individuals having regular access to a mobile device (Moczygemba et al. 2017)), many of the mobile devices provided are unable to support video consultations and those that do tend to be unaffordable (Moczygemba et al. 2017). As a result, with more (healthcare) services shifting to digital platforms during COVID-19, the chasm of digital inequalities continued to widen: 79% of homeless service providers screened reported increasing issues due to lack of digital access for people experiencing homelessness in the first lockdown (Boobis and Albanese 2020).

In an attempt to overcome some of the barriers associated with a lack of suitable technology and inaccessibility, a GP service in an unnamed UK university town trialled the provision of ‘mobile health consulting’ specifically with one so-called temporary ‘COVID-19 hotel’ for people experiencing homelessness. The set-up was simple: use (video) telemedicine to connect people experiencing homelessness in a local Covid-hotel directly (and quasi on-demand) to a specialised GP service for non-emergency healthcare consultations.

The implementation of this new service divided the opinions of both staff and the people who used it in the COVID-19 hotel. While some staff—doctors and nurses alike—fundamentally did not agree with the idea of video consultations as a substitution for (or even addition to) inperson consultations, other staff wholeheartedly supported the idea. Several staff members commented that with the introduction of video consultations, they saw ‘terrific engagement from many clients who would not normally engage with the service’. One key success story was with Brody, one of the residents of the local COVID-19 hotel:

Brody was a deeply entrenched individual; encouraging this person to go to the surgery was always a difficult task […] suddenly, we were able to provide a consultation which meant that all we had to do was go from one side of the building to the other. It was a real success to get him involved. Support worker

The benefit of new and unseen engagement was particularly noted in people with limited mobility. As two people with lived experience noted, not having to travel to see a doctor also made it easier for people who struggle with anxiety or depression (and might not want to leave their house) to connect to healthcare in an environment they felt comfortable in. One person who used the service commented:

While the video appointment was still daunting it was far less scary than a face to face appointment and definitely helped with my anxiety around seeing health professionals

For the healthcare providers, video consultation can also solve several issues at once: they make DNA (people who ‘do not attend’ the appointment) less likely, ensuring the continuing provision of consultation also during lockdown conditions while reducing (inperson) appointments (potentially dangerous for vulnerable people). For one nurse frequently in contact with people experiencing homelessness during street outreach tours, this was a very strong point: ‘It is another string to my bow that I can offer people when I am out on outreach’.

However, from our time-constrained small-scale observations during the one local trial we accompanied, only a certain group of people, a subgroup of people experiencing homelessness, were able to enjoy the benefits. The ‘success stories’ of video consultations we observed were with young male individuals who were already familiar with video communication. Women, older individuals and those who were less comfortable with technology remained less or not at all engaged. This highlights several problems with the service more generally and some general principles of how to design (and test) similar services in the future.