This year, the newly founded, student-run UCD Social Medicine Society hosted an interfaculty competition in which four teams had to come up with and present innovative solutions to this year's question at the inaugural Ideas for Change event: “How do we improve the health of homeless people in Ireland?”  

Homelessness is becoming increasingly prevalent in Ireland. As of December 2016, the number of homeless people, in emergency accommodation, temporary services and homeless families, in Ireland has risen to approximately 7,148 [1]. It is important to note that this number does not include rough sleepers or people living in squats.

Studies demonstrate that homeless people tend to engage with primary health care services less, and often present acutely in emergency settings [2]. A report by Crisis, a British organisation, found that homeless people are almost 40 times more likely to not be registered with a GP than the general population. 79% turn to the emergency department, with 10% using the emergency service once a month [3].

Homeless people have a greatly reduced life expectancy, estimated as 47 years of age in one study [4] and suffer from a greater number of co-morbidities [5] than the general population. Additionally, a study looking at the rate of suicide and self-harm among the homeless in Ireland found that a significantly higher proportion of homeless people (24.8%) engaged in repeated self-harm acts compared to those with a fixed residence (15.1%) with 5,487 (15.3%) engaging in one or more repeated acts of self-harm during the 12 month follow up period since the time of the index self-harm act [6]. The key finding in this study demonstrated that homeless patients were less likely to be offered an outpatient appointment compared to patients with fixed residences6. The report states that the primary reason for this was lack of fixed address and general unpredictability of a patient's living arrangements [6].

In efforts to tackle the problem of housing shortage, the €5.35 billion ‘Housing initiative: Rebuilding Ireland – Action Plan for Housing and Homelessness’, aims to build 25,000 houses per annum from 2017 to 2021. A housing first policy is undoubtedly the most effective intervention that can improve the health and quality of life of homeless people. In the meantime, measures to address the health care issues of the homeless need to be implemented.

Our Ideas for Change 2016 proposal was to provide homeless people with access to secure storage facilities for their personal belongings. It is important to bear in mind that the homeless population in Ireland is a heterogeneous group comprising homeless families, people with mental disorders, people with drug addictions etc. As such, our service is designed to operate on two separate tiers to target what we perceive to be different needs present within distinct homeless populations.

The first service from our proposal is targeted towards families and people transitioning through emergency accommodation or on the brink of homelessness. It is essentially a secure area composed of individual storage units to allow for the safekeeping of the bulky furniture and everyday objects that are inevitably lost when one becomes homeless. Having a secure place to keep these belongings would help alleviate some of the stress and anxiety that are associated with becoming homeless. A large part of a person’s identity is bound to their personal belongings and the emotional value that they attach to them. This facility would mean that just because someone loses their home does not mean that they must go through the further step of losing all of their possessions. Once these people transitioning through homelessness are rehoused, the ability to move their possessions into their new accommodation would reduce the financial strain of refurnishing their new home. This service is intended to be only a temporary measure to help tide over the people who are spending a limited time without a home. It is not supposed to become a long-term storage area that gradually accumulates clutter. Therefore, care will have to be taken to make sure that the system is not abused.

The second part of our idea applies to a broader section of the homeless population. It is to offer secure personal storage spaces, such as lockers, to individuals for the preservation of their personal belongings. Along with a locker, people would be assigned a case manager who would help them engage with healthcare and welfare services. There is currently very limited access to lockers and storage spaces for homeless people in Dublin and no service utilises case management and engages the homeless population in the way that we envisage. The storage lockers would be mainly used to store medications, a clean change of clothes and small objects that may be lost or damaged in the turbulence associated with day to day living as a homeless person. This should help keep people’s belongings safe from theft, damage from exposure to the elements, or simply loss.

Theft is a huge problem in a population that already suffers from a higher rate of comorbidities. A study by Crisis in 2004 found that 67% of homeless people had been victims of theft5. Adherence to prescriptions is estimated to be 50% amongst patients from the general population. Homeless people have higher rates of non-adherence due to problems such as theft, loss, lack of storage space and social isolation [8, 9, 10]. Having a secure area to store these medications would hopefully help to address this issue.

Access to a place to store a clean change of clothes would also be of enormous benefit for people without a home. It offers not only an improvement in quality of life and hygiene, but an infection control benefit. The ability to wash and change clothes is essential in preventing infections such as scabies, which are rife in the homeless community.

Active case management is integral to this plan; case managers would be assigned a small number of people using the lockers with whom they would be in direct contact. As people will be accessing these lockers on a regular basis they should be easy to get a hold of, which is characteristically a problem in homeless healthcare. The case manager would remind people to attend appointments, clinics, promote health seeking behaviour and help them engage with services. It has been shown previously that active case management improves health outcomes amongst homeless people [11]. By combining case management along with secure storage of prescribed medications, we hope to reduce loss of homeless patients to follow-up and hopefully lead to less people with chronic conditions deteriorating and presenting acutely. We would therefore argue that this intervention is not only beneficial to the health and wellbeing of the population that it serves, but is also of benefit to the health service. If proven to be effective, this relatively inexpensive intervention could reduce the financial burden of acute presentations and hospital admissions of the homeless population.

People using the locker service would also be able to use it as a postal address for appointments and correspondence to be sent to. Not having a fixed address is a major obstacle that homeless people encounter in their interactions with the health service and various government bodies. The ability to provide an address where they could be contacted should help resolve part of that problem.

Similar interventions have been carried out in different cities across the world such as Los Angeles and Paris [12, 13]. Although there have been no academic studies on the impact these interventions have had on homeless health, first-hand reports from the service providers and users have been largely positive. We do understand however that there are practical issues that must be addressed before such a plan can be implemented in Ireland.

One obstacle is finding a suitable location for each of the storage spaces, with the lockers ideally being located on the site of an existing homeless service. This would keep the cost down to the purchase of lockers and wages of staff. Purchased new, it would cost approximately €2,742 for 30 lockers [14], which would suit a pilot programme to determine the appropriateness of the scheme for wider implementation. The larger long term space can be situated more remotely, with access being prearranged with a coordinator.  The risk of the service being abused must also be noted and our solution to this would be to control access to the facility, monitor the rooms with surveillance cameras, and implement a zero-tolerance policy for anyone misusing the facilities resulting in denial of access.

Our idea to improve the health of the homeless population of Ireland is a simple one: fulfil a basic need by providing the ability to store important belongings in a safe, dry, and clean space. Storage spaces would be hugely beneficial to this marginalised section of society and we believe that with the additional support of a case manager, the lockers and storage spaces can be used responsibly and have a tremendous impact on the health and wellbeing of the homeless population of Ireland.

1. The Department of Housing, Planning, Community & Local Government  Homelessness Report December 2016.

2. http://www.housing.gov.ie/sites/default/files/publications/files/homeless_report_-_december_2016.pdf

3. Bolster, D., Manias, E. Person-centred interactions between nurses and patients during medication activities in an acute hospital setting: qualitative observation and interview study. Int. J. Nurs. Stud. 2007;47:154–165.

4. Crisis, (2002). Critical condition: Homeless people's access to GPs. [online] Available at: http://www.crisis.org.uk/pressreleases.php/120/homeless-people-left-out-in-the-cold-when-it-comes-to-healthcare.

5. Crisis (2011), Homelessness: A silent killer. A research briefing on mortality amongst homeless people, December 2011. [online] Available at: http://www.crisis.org.uk/data/files/publications/Homelessness%20-%20a%20silent%20killer.pdf

6. Institute of Medicine (US) Committee on Health Care for Homeless People. Homelessness, Health, and Human Needs. Washington (DC): National Academies Press (US); 1988. 3, Health Problems of Homeless People. Available from: https://www.ncbi.nlm.nih.gov/books/NBK218236/

7. Haw, C, Hawton K, Casey D. "Deliberate self-harm patients of no fixed abode." Social Psychiatry and Psychiatric Epidemiology 41.11 (2006): 918-25.

8. Crisis 2004: Living in Fear: Violence and Victimisation in the Lives of Single Homeless People, Crisis Report 2004.

9. Nyamathi A, Shuler P. Factors affecting prescribed medication compliance of the urban homeless adult. The Nurse Practitioner. 1989;14(8):47-8.

10. Whitney M, Glazier R. Factors affecting medication adherence among the homeless: A qualitative study of patient’s perspectives. University of Toronto Medical Journal. 2004;82(1):6-9

11. Breakey W. Treating the homeless. Alcohol, Health, and Research World. 1987:42-47, 90.

12. Hwang S, Burns T. Health interventions for people who are homeless. The Lancet. 2014;384(9953):1541-1547.

13. Bagagerie Association Mains Libres. Paris. Available at: http://www.mainslibres.asso.fr/wordpress/

14. Gonzalez S. Inside LA’s storage facility for homeless people. KRCW.  February 18 2016. Available at: http://curious.kcrw.com/2016/02/storage-facility-for-homeless

15. Price for Salsbury See-Through Metal Locker - Double Tier - 3 Wide - 5 Feet High - 15 Inches Deep. Available at: http://www.lockers.com/products/see-through-metal-locker-double-tier-3-wide-5-feet-high-15-inches-deep/?F_Filter1=1%3a5%27%2bHigh&F_Filter2=2%3a15%2522%2bDeep