Blog by Johannes Lenhard, Eana Meng, and Meg Margetts

The overall support for homeless people—those who are often forgotten—in the UK during the Covid-19 pandemic was unexpectedly generous. Service providers and homeless people and in particular those sleeping rough received an enormous amount of help, especially when the lockdown first started in March. Financed mostly by the Treasury under an extension of the ‘Homelessness Initiative’ of 2018, the scheme, entitled ‘Everyone in’, was focused mostly on providing housing and a basic level of support. While effective for some, with 15,000 now housed, originally some groups were left behind and excluded, particularly from healthcare. Furthermore, questions remain about longer-term plans (as government funding is running out) and implications. We wanted to draw first reflections and ask: what can we learn from the past few months about alleviating the quality of life of the homeless population?

Applying rapid ethnographic assessment with a focus on listening to different stakeholders in the community, Eana Meng and Meg Margetts worked within two different projects with PI Johannes Lenhard; we conducted several months of (anthropological) fieldwork and semi-structured interviews (adhering to Covid-restrictions) in a variety of homeless support institutions in a UK university town between April 2020 and March 2021. There are two key findings we want to present with regards to healthcare inclusion and propose what we believe are important implications for future healthcare provisions for people experiencing homelessness.

1. Some of the most marginalised people fell through the support net: As many more specialised support services, particularly around addiction and mental health, were either partly suspended or moved online (often until today), people in those demographics struggled in two interconnected ways. With drugs harder to come by and no money from begging practices due to the restrictions to go outside, a number of people disobeyed quarantine orders (e.g. in supported housing) to obtain drugs, often in fear of withdrawal symptoms. Lockdown not only created a disruption of normal routines, but it also quasi-criminalized them, either by government imposed or institutional (lockdown) rules. As a result of the ‘misbehaviour’ and ‘disobedience’, some residents were evicted from the support institutions, as a means of protecting others, with nowhere left to go but the street. This in turn left them further marginalised from the necessary healthcare support beyond street outreach (which laudably was in operation throughout most of the lockdowns).
2. Shift to digital care did not work: This was especially felt by mental health services, where support workers reported a lack of engagement, as some people were missing appointments or remained unwilling to engage. Workers and people experiencing homelessness explicitly expressed difficulties connecting with each other over video or phone calls. Virtual group-based work was especially disliked, and the camaraderie of a sense of community was lost when going virtual. As one support worker told us, “We’re meant to connect!” and the absence of those connections was especially hard on those dealing with mental health conditions such as anxiety, depression, and psychoses further exasperated through the pandemic and its consequences. First experiences of providing tele-medicine for the homeless community show promising results while question marks around digital exclusion remain (e.g. the utilisation of video consulting to provide community-based buprenorphine treatment for homeless patients).

Based on our key findings, we believe there are several tangible suggestions that can be made from our analyses and conversations within the community, most importantly with people experiencing homelessness themselves.

1. Specialized attention should be paid to those struggling with addiction and mental health. The safety net only worked for some, and became punitive for others. More resources should be allocated to services that provide for people with complex needs, such as hiring support workers with training in dual diagnoses. Services should also be adapted to facilitate routines in these populations, and we believe a harm reduction approach, such as encouraging the use of safe injection facilities, would have drastically benefited both institutions and individuals alike (e.g. by providing a safe space also for people that remained sleeping rough). Increased outreach with proper precautions such as directly reaching out to people experiencing homelessness and providing essential supplies have proven beneficial.
2. Incorporate, encourage, and normalize use of digital services. Despite the rocky shift to digital services, so far we suspect much of the difficulties were due to the fact that digital services were novel to support workers and people experiencing homelessness alike. We believe that with time, people will adjust. Studies have shown that mobile phone-based intervention could be beneficial in improving mental health among young homeless adults; additional studies have highlighted the utility of cell phones in providing community-based buprenorphine therapy for homeless patients. We believe the wider use of digital tools— also under non-crisis circumstances—can indeed be an opportunity for increased and more personalised care. It is important, however, to ensure that a number of conditions are met for a successful consultation: access to a private and safe space for consultation, adequate connection to the internet and necessary hardware, and the availability of technology support and training (especially also for healthcare staff).

Overall, the Covid-19 pandemic has provided substantial short-term alleviations for some people experiencing homelessness with possibilities for long term change. Novel policies have pushed many slowly developing approaches—especially around digital platforms—into a much quicker and wider experimental adoption. We hope that both from a health and housing perspective we take the learnings the pandemic has accelerated seriously and continue the path also for long-term solutions focused on inclusion.

Dr Johannes Lenhard is an ethnographer of homelessness and most recently venture capital at the Max Planck Cambridge Center for Ethics, Economy and Social Change.

Eana Meng is a physician historian in training at Harvard Medical School and the Department of History of Science. Her research focuses on social history of alternative medicines, with a particular emphasis on community-based healthcare, addiction, and pain management.

Meg Margetts is a 4th year Medical student at Cambridge. She completed her bachelor’s degree in psychology, neuroscience and behavior and her research interests are in social inequalities with a particular focus on homelessness.