Printed on: April 17th, 2026

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Homelessness

Homelessness

Let’s start with some shocking numbers that will highlight why this is such an important issue (BMJ 2025:388:e08768):

• It was estimated that, on a given night in England in 2024, over 350 000 people were experiencing some form of homelessness – that’s 1 in 160.
• 90% of those experiencing homelessness have been subjected to 1 or more adverse childhood events (this includes physical, sexual or emotional abuse; living with someone who abuses alcohol/drugs, has a serious mental illness or has been in prison; being exposed to domestic violence; and losing a parent through divorce, death or abandonment).
• The average life expectancy of the homeless population is 30 years lower than the general population. That’s not a typo. 30 years shorter life expectancy. What is more, 30% of the premature deaths are due to causes that can be modified with effective healthcare. Health and homelessness are intimately related.
• A homeless ‘mystery shopper’ with an urgent health problem that needed same-day attention was sent to 13 practices in London in 2024. Over half the practices refused to register the patient, despite them having an urgent health need – often because of the inability to provide proof of identity or proof of address.

What do we mean by homelessness? This may include (BMJ 2025:388:e08768):

• Sleeping rough.
• Living in temporary accommodation (night shelters, hostels, women’s refuges).
• Hidden homelessness (living in a squat or ‘bedsheds’, sofa surfing, staying with friends).

Homelessness may be short or long term.

The support needs of homeless people vary hugely and depend on many factors. A one-size-fits-all approach is unlikely to work. A critical part of care is getting alongside people, identifying their needs and working to meet these. This requires an individualised approach.

More effort and targeted approaches are often needed to ensure that those experiencing homelessness receive the same level of health and social care as the rest of the population (NICE guidance on integrated health and social care for those experiencing homelessness, NICE NG214, 2022).

This article was last updated in July 2025.

The causes of homelessness are wide-ranging, complex, often multifactorial and interdependent. Despite the causes rarely being related to individual choices, research shows that people who are homeless experience stigma and discrimination from healthcare professionals who fail to understand the complex issues underlying homelessness. People’s individual choices are often blamed (BMJ 2025:388:e08768).

Homelessness is an indicator of social exclusion. Often, other markers of social exclusion – such as adverse childhood events or substance misuse – may be present, and these can also have a profound effect on health.

The BMJ paper highlights a systematic review from the US and Canada that identified barriers to healthcare among homeless people – both barriers at the point of care and internalised barriers within the homeless person. The review also highlighted systemic issues particularly pertinent to the NHS and based on data from the UK (BMJ 2025:388:e08768). How can we address these at a system level and with individuals we care for?

90% of those who are homeless have experienced 1 or more adverse childhood events (this includes physical, sexual or emotional abuse; living with someone who abuses alcohol/drugs, has a serious mental illness or has been in prison; being exposed to domestic violence; and losing a parent through divorce, death or abandonment) (BMJ 2025:388:e08768):

The Office for Health Improvement and Disparities describes 6 key principles of trauma-informed practice (Nov 2022):

For more information about trauma-informed practice, including practical tips on talking about trauma and implementing trauma-informed practice in organisations, see our article Trauma-informed care.

As mentioned in the introduction to this article, people experiencing homelessness can have difficulty registering with primary care. In London in 2024, one homeless ‘mystery shopper’ was turned away from over half the 13 practices they spoke to, despite having an urgent health problem that needed same-day attention. The main reasons given for refusing registration were inability to provide proof of identity or proof of address BMJ 2025:388:e08768). So, what do you need to register a patient?

The NHS website – how to register with a GP surgery offers the following advice to patients (quoted directly from its webpage, accessed 22 August 2025):

“You do not need ID, proof of address or proof of immigration status. Having an NHS number can make it easier to find your medical records, but you do not need one to register…If you do not have a permanent address, you can register with a GP surgery using a temporary address or the address of the GP surgery.

A GP surgery may refuse your registration if:

• They're not accepting new patients.
• You live outside the surgery's area.
• You have been removed from their patient list before.”

NICE issued this guidance in 2022 (NICE NG214, 2022).

It is broad ranging so we have provided a very brief summary of the key themes below.

NICE defines homelessness much as at the start of this article, but the guidance also covers those with a history of homelessness who are at high risk of becoming homeless again because of ongoing severe and multiple health and social care needs.

• More effort and targeted approaches are often needed to ensure that those experiencing homelessness receive the same level of health and social care as the rest of the population.
• Services should be co-designed and co-delivered with people with lived experience of homelessness in order to improve the quality.

• Support initial and sustained engagement and re-engagement.
  • Use empathetic, non-judgemental personalised care. Consider using psychologically-informed or trauma-informed care (as described above).
  • Longer contact times may be needed to develop/sustain relationships. Consider reducing caseloads and lengthening contact time for health and social care practitioners working with people experiencing homelessness; this will allow them to build and sustain engagement.
  • Promote shared decision-making and build self-reliance using a strengths/assets-based approach; this involves identifying an individual’s strengths/assets (relationships, skills, experience, aspirations) and community assets (knowledge, people, spaces, networks services), rather than focusing on what an individual doesn’t or can’t do.
  • Engagement may be support by offering flexible services: flexible appointment/opening times, ‘one-stop’ shops, incentives to access care (e.g. transport, vouchers, digital connectivity).
  • Do not penalise people who miss appointments/self-discharge from services (and ensure other services do not do this either).

• Ensure good communication (with the patient and other services).
  • Ensure the person experiencing homelessness knows what services are available/what rights they have.
  • Ensure good communication around transition between services (e.g. on discharge, transitioning from children’s to adults’ services, when moving from supported living into private landlord accommodation).
• Support people to register with a GP. Address any difficulties with GP registrations for people experiencing homelessness.

• Health and social care should monitor homelessness and housing statistics, and develop services to meet these needs.
• Housing services need to provide appropriate accommodation, which may include self-contained accommodation and accommodation with support (health, social care), in order to support long-term recovery.
• Health/social care and housing services should provide integrated multidisciplinary health and social care services. These might include:
  • Peers.
  • Clinicians (e.g. drug and alcohol team, mental health, primary care, emergency care, palliative care).
  • Social workers.
  • Housing officers.
  • Outreach workers who take health/social care to the patient.
  • Voluntary/charity sector.
  • Staff experienced in accessing benefits.
• These integrated multidisciplinary health/social care teams should also provide support to mainstream providers.
• The following services are also needed:
  • Intermediate care for those being discharged but not yet able to manage safely in the community.
  • Long-term support services to reduce the chance of disengagement and returning to homelessness.

• Ensure appropriate safeguarding (at an individual and structural level). As part of this, Local Safeguarding Boards should consider having a lead for people experiencing homelessness.

	Homelessness The definition goes beyond those sleeping rough on the streets. Causes are multifactorial, and are often outside the control of the individual. People experiencing homelessness have often been subjected to significant childhood trauma. This can negatively affect their behaviour and engagement with services. A ‘trauma-informed’ approach allows people to feel safe. It also empowers them, which helps them to engage. Health outcomes for those experiencing homelessness are very poor. Research shows that 30% of premature deaths are due to causes that could be modified with effective healthcare. There are multiple barriers to accessing healthcare for those experiencing homelessness, but there are solutions to many of these barriers. Additional time and effort is needed to support those experiencing homelessness, and this should be recognised when designing healthcare systems. Do you have double appointments for patients experiencing homelessness? What other modifications to your way of practice and systems might you consider making?
	Review the service you are working in. What changes might you want to make after reading this article? This might involve ease of registration, staff attitudes and behaviours, length of appointment, looking at barriers, involving those experiencing homelessness in service design, and advocating for those experiencing homelessness if they experience barriers in other health/social care settings.
	Useful resources: Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge) Pathway (focuses on homelessness and health inclusion)