Niamh Brophy from St Ann’s Hospice in Greater Manchester and Alison Colclough from St Luke’s Hospice in Cheshire, write about the challenges of delivering end of life care to homeless people during the Covid-19 pandemic.
When the world we know is shaken by its very roots, for most of us our place of retreat is home. But what if we don’t have a home of our own? Maybe we are sofa surfing, on the street or in a hostel – what do we do then?
Coronavirus struck the UK with force in March 2020. Within three weeks society was shutting down, people were required to self-isolate, to practice social distancing and to live in a way no one in our country has been required to do since World War Two.
On 27th March, local authorities were given the green light to get all of their rough sleepers and those using night shelters indoors to help prevent the spread of the virus. Homeless hostels and emergency accommodation became full.
41 per cent of homeless people are already in a high risk category due to pre-existing conditions. As a population, they are probably as vulnerable to the impact of Covid-19 as a population of people living in a nursing home. It means many must self-isolate, but in a hostel with shared facilities this is almost impossible to do. For some, social distancing may not take priority if mental health issues or an addiction are also at play. How do they get their methadone or alcohol in order to prevent withdrawal?
There has been copious amounts of guidance, including the Covid-19 Homeless Sector Plan, which details how rough sleepers and people using night shelters were triaged and placed in hotels to enable them to socially distance and self-isolate. However, hostel residents are still at higher risk, and this left hostel staff with anxiety over how to deal with certain Covid-19 related scenarios.
There have been mixed messages on where to get PPE when needed. The Department of Health and Social Care has been taking strides to ensure adequate PPE and other vital equipment can be provided in the community, but for care homes rather than hostels. Community nurses are expected to wear an apron, gloves and water resistant mask when attending to patients who are not Covid-19 positive. Where could hostel staff get such equipment if they fit in to neither health or social care?
Some local authorities ensured their accommodations had stock, some CCGs shared their stock but others did not, and it is unclear where charity-based hostels got theirs, if they got any at all. A consistent approach is needed.
Amid this cacophony of information many hostels rose to the challenge, as did local drug and alcohol teams who came up with practical ways to ensure people could still socially distance or self-isolate and get their addiction needs met. NHS and social care staff worked miracles, but so too did hostel staff.
Some hostels gave all of their service users a kettle and tea/coffee making facilities to restrict visits to shared kitchens. Staff went shopping for those self-isolating and delivered medications, taking on more tasks at a time when their own staff numbers were diminishing.
A document supporting this effort was drawn up by GP Dr Beale, with the aim of supporting hostels to ensure they were prepared for the duration of the pandemic. Following on from this, a list of recommendations was created so hostels can utilise available support during such difficult times. Among these recommendations was a call for hostels to be provided with IT facilities to support video consultations with health professionals.
Even with this support, a key concern remains. For this vulnerable population who already have a life-limiting illness, how do they access good palliative care?
Palliative care staff from hospitals and hospices must limit face to face support in order to prevent further spread. Yet guidance has been issued by the British Medical Association around Advance Care Planning (ACP) in light of the pandemic, encouraging health professionals to ensure their patients with advanced illnesses have ACPs in place that address goals of care and ceilings of treatment in the event they become critically unwell.
Supporting a person with complex needs and sometimes chaotic behaviour is already difficult; only being able to chat on the phone makes it harder still. Some difficult conversations around ACP still need to go ahead, but these sorts of conversations become extremely difficult without the advantage of face to face contact.
For these individuals placed in Covid Protect hubs across the country, ACP conversations should take place as part of the assessment process and intake by professionals who feel confident and knowledgeable enough to have such discussions. At the very least, homeless sector staff should be supported to record Next of Kin details where possible to ensure family can be contacted in the event someone dies.
In Manchester, Cheshire and London, specialist coordinators from hospices and homeless charities work specifically with the homeless to access good palliative and end of life care. But during the pandemic it became increasingly difficult to do this. The question changed from ‘how can we support and facilitate a good death’ to ‘how can we support the hostels to ensure people survive this virus.’
Now that lockdown is easing and the homeless hotels are closing, there is concern that the most vulnerable risk returning to the streets with little support in place to address their complex needs. Many homeless services report a worrying concern in the rise of numbers of homeless people as a direct result of the pandemic. The true scale of this is not yet known but councils have warned up to half a million people could become newly homeless in the months to come.
For those with deteriorating health the concern remains the same. With numbers of homeless increasing and services still reeling from the pandemic, where will the most vulnerable be housed? How can we ensure access to the right care at the right time? And is there a role for digital technology to support engagement with health services and promote treatment continuity?
By raising awareness of these unique challenges we hope to feed into a much needed conversation to ensure adequate contingency plans are in place to support the most vulnerable in our society in the most trying of times. In doing so we could avoid emergency admissions to hospital, not only to reduce the burden on the NHS at such a critical time, but to protect and support these individuals and honour their wishes as much as we can.
For more information on tackling inequalities in end of life care visit Care Committed to Me