The first night Sofia spent in a Dublin hostel, she was petrified. “You walk through this pathway surrounded by metal, like a jail, and then you’re in a warehouse with people staring at you like a pack of wolves.” Sofia ended up homeless more than two years ago, at the age of 30, after a relationship broke down.
“I was in hospital for a month for my mental health after that breakup and when I left I’d nowhere to live,” she says. “Once you’re in a cycle you get stuck and I developed a very bad drinking problem.”
The number of homeless people in Ireland has doubled in four years, reaching 5,000 in Dublin alone. Their physical and mental health is fragile. Life expectancy for homeless women in Dublin is 38. For men, it is 42.
These challenges seem insurmountable. But Dr Clíona Ní Cheallaigh thinks otherwise. For her, a solution is to be found in a more joined-up medical approach designed to stop marginalised individuals bouncing around between hospitals and the streets with no single service “owning” their care.
Ní Cheallaigh, who is a hospital consultant, heads up a service for socially excluded groups, including homeless people. The programme she has established at St James’s hospital is unique. And it looks like it is working. She has always had a strong sense of social justice. Both sets of her grandparents grew up in inner-city Dublin tenements. But the idea of this service grew during her training in HIV medicine.
“If you take HIV tablets daily and come to clinic twice a year, you’ll have a normal life expectancy,” she says. “Yet there was a small cohort in their early 30s who just wouldn’t do either.”
By the end of her first year all those patients were dead. There were practical reasons for missing appointments. They could not afford taxis, or had no family to bring them.
Ní Cheallaigh set about rethinking how to do care for people are socially excluded. “You set up drop-in services, have people remind them to come, pay for taxis.” Then they can stay well, have relationships, look after their kids. The alternative: watch them die young.
It is part of a broader approach called inclusion health which addresses health and social inequities among the most vulnerable and excluded (homeless people, individuals with severe mental health issues, drug users and prisoners, for example). Its foundation lies in the integration of health and social services.
St James’s has the first hospital-led inclusion health team in the world. This is important because homeless people are five times more likely to attend A&E but up to 40% leave without being seen. They are 3.2 times more likely to become inpatients with longer stays and more readmissions.
When homeless patients arrive to A&E, they are flagged up on the system so Ní Cheallaigh and her team are aware. These patients get pyjamas, socks, underwear, toothpaste and a toothbrush if they wish. “If you’re feeling shamed [about being unkempt], you’ll try to reassert status or you’ll leave.” Every one of these medical patients goes under her care.
But care must go beyond patching people up and returning them to the streets. Further down the chain, a homeless and drugs charity by the river brings Ní Cheallaigh together with social workers, nurses, psychiatrists, accommodation providers, addiction workers, and GPs once a week.
Here, a housing officer talks through options for Sofia. A keyworker has found a missing patient. The ideal is to prevent medical complications and indeed homelessness, but rough sleepers often flit between hospitals; without this meeting, they might fall through the gaps entirely.
Ní Cheallaigh heads to her next stop of the day. “Funnily enough, it’s the old tradition of medicine,” says Dermot Murphy, who is a senior services manager for DePaul at Sundial House, a long-term accommodation unit for chronic street drinkers. “Bring the doctor to the patient, not the patient to the doctor.”
This approach is distinctive, Murphy believes. “Being consultant-led – it gives a sense of gravitas and strength that’s changing the hospital’s focus. It couldn’t be done if it was GP-led because it’s a silo, that place. Beyond the hospital doors, you’re on their grounds.”
Christy, 60, has benefited from the coordination of care. “Heart attacks, brain clots, fractured legs, a broken back. You name it, I’ve had it,” he recalls. Now, his nurse has a direct dial to the inclusion health team. His health issues have abated. He has stopped drinking. “I’ve an exercise bike and I do my best with that. I’m trying to lose the belly. I’ve cut down on the biscuits and chocolate. Maybe someday I’ll move out but not now. I’ve a beautiful life here.”
One argument is that these patients are getting special treatment. But that’s the point.
“NHS trusts, they’re like here – large entities of bureaucracy that are meant to work with the mean,” says Murphy. “We’re saying there are a significant number of outliers whose needs can’t be met with this traditional model. Asking someone with a chronic heroin or alcohol addiction to attend an appointment at a specific time is slightly ludicrous.”
He adds: “Working with a consultant who is willing to walk out of the hospital and go ‘this man absolutely needs an appointment and I’ll make myself available when you can get them to the hospital’ – that’s the difference between saving that person’s life and that person dying.”
Ní Cheallaigh’s service saved almost €1m (£904,000) in direct costs to the hospital and 3,066 bed days in a year-long pilot study. Yet finance for the service remains uncertain, with no promise of extension beyond a two-year funding round.
Back at St James’s, Sofia recounts a previous visit to another hospital. “They left me sat in the waiting room, vomiting in front of people. They discharged me at 2am, a female on my own.” But St James’s was different. ‘The two times I’ve come here before, they’ve brought me straight through. I didn’t feel judged.”
Since her latest hospital admission,she has detoxed fully and is being discharged to a residential recovery unit. The inclusion health team will keep tabs on her.
“I’m going to get my life back,” she says. “I’m shocked I’ve lost everything the way I have but in my head if you’ve had it once you can have it again.” Her hospital team here looked beyond a bed for the night. And with that, they might just have given Sofia a new beginning.
This article is part of a series on possible solutions to some of the world’s most stubborn problems. What else should we cover? Email us at firstname.lastname@example.org