HC Deb 29 July 1980 vol 989 cc1475-86

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Brooke.]

1 am

Mr. Ernie Roberts () Hackney, North and Stoke Newington

Many people for whom I speak in this debate have already gone to their beds on park benches, or in shop doorways, disused factories, empty or derelict properties, or on the pavements, or are squatting. The rest are still wandering about seeking shelter and a place to rest their bodies.

It is estimated that there are about 100,000 such people in the United Kingdom. About 60,000 of them are in hostels or lodgings each night. In London on any night about 2,000 people sleep out. In Hackney there are about 3,000 single homeless people. They are homeless, rootless and healthless.

Not many people care about the single homeless. They say that they smell, that they are ragged, drunk, or mentally ill. People are embarrassed by them. They cannot get medical treatment when they are ill. General practitioners, who are legally bound to give treatment and are morally bound by the Hippocratic oath to serve the sick, reject the down-and-out single homeless for fear of offending their respectable clientele.

The single homeless are driven to hospitals and casualty departments for primary treatment. Generally they are received sympathetically by overworked casualty staff. The homeless come to rely on them to provide treatment for ills brought on by their homelessness. Complaints such as bronchitis, tuberculosis, dietary deficiencies and foot problems are suffered by people who sleep rough or who are turned out of hostels at 9 am to tramp the streets and search for food or work.

Hospitals that are already overcrowded and starved of finance admit in-patients only as a last resort. The case of Tom Fraser has been reported. He was a 57-year-old homeless man who died alone and untreated in a local graveyard after being turned away twice from a Hackney hospital because casualty staff considered that he was drunk. The post mortem revealed that he had sustained a fractured skull and had died of brain haemorrhage. That is one among many similar cases. People who are admitted to hospital are treated and discharged without the hospital authorities realising that they have no homes. They return to the streets and their illness recurs.

The Hackney community health council produced a report. It looked comprehensively at the range of health care facilities—primary care, casualty, hospital after-care, psychiatric and alcoholic services—available for the homeless in the district. It found that GPs were unwilling to accept single homeless patients. Four out of six doctors approached by a homeless man refused to register or treat a patient without a fixed address. Casualty departments were unable to ensure proper treatment in every case. Homeless people without a GP have relied on casualty departments for basic medical care. Yet inner city casualty units have been cut and those remaining open are shedding their primary care functions. Hospital wards were discharging unsupported single patients home to recuperate in insanitary hostels or on the streets. This practice undoes the benefit of hospital care but, as with most inner city districts, there are no aftercare facilities such as half-way houses or hostels, or sick bays in the City or Hackney areas.

The Hackney community health council has made constructive proposals on how services can be improved. It suggests the active encouragement of GPs to register more homeless patients on their lists, so that single homeless people can be reintegrated into the mainstream of the Health Service, where they belong as of right. Another proposal is for an educational role for the area health authority in developing the understanding of Health Service personnel of the social background and needs of homeless patients.

The council calls for a systematic check on patients at hospitals to discover whether they have a home and a GP to go to on discharge, and the provision of a small, local after-care unit. It also calls on the Government to allocate money earmarked for the development of services for specific deprived groups in our communities, because the problems of the single homeless are national. We have to ask the Government to stop cutting back the financial support given to voluntary agencies providing succour for the suffering single homeless. The GPs are not responsible for these problems; they are on the receiving end of a number of problems in the lives of the homeless, the rootless and the jobless.

The single homeless are not all vagrants, alcoholics or mentally sick. The 1977 report of the Supplementary Benefits Commission, presented to Parliament by the Secretary of State, in a chapter headed "People 'without a settled way of living'" refers to 'persons who have shown a continuing failure to cope with the demands of society, to form personal ties, to find or hold employment, to find a place to live, and to respond to rehabilitation or deterrence.' The Home Office point out that this description is coloured by their particular interest in this group as being likely to offend, but it is nevertheless a useful description of a group of people who, while 'at risk', are not necessarily offenders. The report goes on to say that section 24 of the 1824 Act, the basis of modern vagrancy legislation, prohibits a person 'wandering abroad and lodging in any barn or outhouse or in any deserted or unoccupied building or in the open air or under a tent or in any cart or wagon and not giving a good account of himself.' This offence is, however, limited by section 1 of the Vagrancy Act 1935 which makes it necessary to prove either:—

  1. (a) that the person concerned has on the occasion in question been directed to a reasonably accessible place of shelter where accommodation is regularly provided free of charge and has failed to apply for or refused accommodation there; or
  2. (b) that he is a person who persistently wanders abroad and, notwithstanding that a place of shelter is reasonably accessible, lodges or attempts to lodge as provided in the section; or
  3. (c) that by or in the course of such lodging he causes or appears likely to cause damage to property, infection with vermin or other offensive consequence.'"
Those are the descriptions given to people without a settled way of life. Who are these people? The majority of the single homeless are not in this category, as is evidenced by the facts gathered by the After 6 housing advisory service. During 1979 the cases of 9,600 single homeless were referred to it. Of these, 50 per cent. were under 25 years of age; 60 per cent. were working; 8 per cent were on social security. Of those working, 59 per cent. were getting less than £50 a week and could not afford private rented accommodation. Of those referred, 33 per cent. had only accommodation problems; 18 per cent. had marriage or family breakdown; 4 per cent. were eviction cases; 32 per cent. were job seekers in London—and that is an important factor. Only 7 per cent. had drink or drug problems.

This organisation, which gives 24-hour cover for the homeless, is suffering from financial cuts by the Government. I find that 18 voluntary hostels in East and North London are in jeopardy from Government cuts. In my constituency one organisation, called Roma, which deals with drug addiction, has been closed because of the Government cutback.

I move to another report, on the Great Chapel Street medical centre for the young homeless under 25 years of age. It has examined 364 cases referred to it over the past year by many organisations. Of those 48 young people were suffering from coughs, colds, influenza and chest pains. A total of 26 were suffering from skin diseases, scabies, boils, lice, and so on. A further 32 were suffering from sore and blistering feet, and other foot problems. A total of 28 suffered from internal and stomach complaints, 40 from depression, insomnia and psychiatric problems, and 28 from drugs and alcoholic problems. These are just the kind of complaints that young people seeking work in London would contract. I urge the Minister to draw that fact to the attention of the Prime Minister when she advises young unemployed to leave their homes and seek work in places like London and the other great conurbations. These young people need jobs and homes as well as medical treatment.

The organisation reports on what it calls a typical case. A typical patient is a 21-year-old man. He is single. He was brought up in Scotland and is a Protestant. Although he is registered with a doctor at home he has no doctor in the Greater London area. He has been in London for about three weeks. He is looking for a job. At home his last job was as a labourer, but he is happy to take any job in London. Since he has been in London he has made no attempt to register with the local doctor, mainly because he has not needed medical attention. He now has a sore throat and a cold and thinks he might have 'flu. He spent the previous night at the West End reception centre, and was referred to the medical centre by that body. This portrait is drawn from the data collected from the files of 150 similar cases in that centre.

In its issue yesterday the Evening News pointed out that there will be an invasion of young people into London seeking jobs. The forecast is that in this region unemployment could double to 633,000 as a result of that kind of invasion. The problem of the young homeless will therefore grow. They will have all the problems to which I have referred.

Let me refer here to the case of young Tim, which can be regarded as a typical case. Tim has painful feet from walking around in cheap shoes. He has also had a cold and chest pains for the past few days. When the nurse is free, the administrator shows him into her room and gives her his file. She looks at his feet, which are badly blistered. She washes them and then applies medicated foot powder. She gives him the remainder of the tin for his own use in the future. She also advises him to try and wash his feet and socks nightly. Tim mentions to the nurse that he has been feeling ill for the last few days. She asks him what his symptoms are. After taking his temperature and pulse she suggests that he returns to the waiting room until he can see the doctor. After examination, the doctor diagnoses that Tim has bronchitis. Normally, this complaint can be treated by antibiotics and a couple of days in bed; but Tim has nowhere to stay and has been sleeping rough. On the doctor's instructions, he is given a course of antibiotics by the nurse and told how many to take each day. And so he will be back again in the hospital and probably in a more serious condition. These are the conditions under which the single homeless are living in London and other parts of the United Kingdom.

This problem will get worse. That is why I was concerned about raising it. The 2 million unemployed—who were told by the Prime Minister to leave their homes in South Wales, Scotland, the North-East, of wherever to seek work elsewhere—will arrive in the South-East, in London, and many of them will find themselves destitute, without a job or a home. They will sleep on park benches or in doorways, as they did in the 1930s. These are the single homeless as well. Speaking personally, I remember being driven in the 1930s from my own parents' home by unemployment and the means test in the same conditions as now exist. I also remember walking the streets for three years as unemployed. I appreciate the conditions that these young people are experiencing as a result of being thrown out of work, seeking employment away from their homes, finding themselves on the streets, and becoming the wandering, homeless, so-called vagrants, the number of whom is growing.

In Hackney there are 200 young homeless squatting in Morley House. Many have a job, but no home or GP. Hackney borough gets up to about 30 single, childless, homeless couples each week. All that they receive is advice about bed-and-breakfast hotels, or other agencies. About 300 persons go on the housing waiting list every month. One-third of these are single homeless people. There are 13,000 on the waiting list in our borough. One-third of these are single homeless people. In the next 12 months Hackney's supply of housing will be 2,263, from all sources. There will be a likely demand for 15,000 dwellings. That is the main reason for the homeless and healthless in Hackney.

Today I saw a heading that is in most of the national newspapers. It says Charles to pay £1 million for country home? He is a single person who certainly will not be homeless but who will spend a considerable sum of money to provide himself with another home. He is quitting Chevening House, which is a 115-room mansion near Sevenoaks, Kent. Perhaps he or the authorities can be persuaded to allow the young, single homeless, healthless of London to occupy that property. This is a problem that must receive the attention of the Government, and the finance must be made available.

1.18 am
The Under-Secretary of State for Health and Social Security (Sir George Young)

I am grateful to the hon. Gentleman for the opportunity to speak on this subject. In the time that is available to me I should like to concentrate on the health aspect of the case that he has raised, and perhaps ask my hon. Friend the Under-Secretary of State for the Environment to write to him about the homeless aspects that he mentioned.

Of course, the Government are concerned about the health needs of single homeless people. I am well aware of the cases concerning individuals which have been cited by the City and Hackney community health council in the report "Homeless and Healthless", which I have read. I have also read of the sad case of Thomas Frazer, which provided the initial inspiration for the production of the report.

It has been suggested by the community health council and by the hon. Gentleman tonight that the best way to meet the hidden needs of the homeless for health care would be by allocating special central Government funds for the purpose. In support of this, I recognise that it can be argued that the mobility of this group and some of their less attractive characteristics are obstacles to meeting their needs out of limited local resources. It is the belief of Government, however, that this would not be the right answer, either in the long or the short term, for the following reasons.

First, to provide a national allocation for one group would mean deciding how much total money to allocate, how it should be divided between different areas and between the whole range of health and social needs for this group of clients within these areas. How should control be exercised? Who should do this? Where would they get their information from if not from the authorities already providing local services? At a time of economic constraint this additional operation would put an extra burden upon the management of the health services which we would like to avoid. It would also distort priorities.

I want now to explain the specific ways in which the health needs of homeless people can be met within services in the population generally and to answer the particular points raised by the hon. Gentleman. I refer first of all to the ways in which the homeless are provided for within the existing arrangements relating to health care by general practitioners.

It is not uncommon for any person to find that the first doctor he approaches cannot or does not wish to take him on. This experience is by no means confined to the homeless and rootless. If a person is unable to find any doctor willing to accept him, he can ask the local family practitioner committee to assign him to a doctor, who is then bound by his terms of service to take him.

In practice, family practitioner committees manage to find a doctor for people who apply to them, whether using their powers of assignment or otherwise. I believe these arrangements generally work well. They help to secure that people register with doctors who are not unsympathetic to any group they happen to belong to, or to their lifestyle.

For a person to be accepted voluntarily by a doctor or to be assigned to a doctor, it is not essential to have a permanent residence, though I recognise that a person who does not have one may encounter greater difficulties in getting a doctor to take him on.

The voluntary system inevitably means that certain sympathetic doctors may take on more than their fair share of homeless people. However, the allocation system acts as a safety net, in that an overburdened doctor may ask for cases to be redirected by assignation.

Registration on a doctor's list is not the only way in which a person can get the services of a family doctor. If he is staying in an area temporarily—for more than 24 hours, or up to three months—he may ask any doctor practising in the area to accept him as a temporary resident. This, like registration on a normal basis, is voluntary on both sides, but the family practitioner committee will help if a person has difficulty in finding a doctor. The community health council will also give advice where necessary.

There is also provision that a person who is in need of immediate treatment may approach any doctor who provides NHS services in the area where he happens to be, and that doctor is obliged to give the patient any treatment that is immediately necessary for up to 14 days or until the patient is accepted elsewhere as a temporary resident, whichever occurs sooner.

Where a family practitioner committee experiences difficulty in finding doctors willing to take on the care of residents in hostels or other establishments for the care of the homeless, it can, even if its area is one with sufficient doctors, seek the admission of an additional doctor for the limited purpose of providing general medical services to residents of these hostels. It will find that there are some doctors prepared to take a special interest in this work.

For example, doctors in the area were for some time prepared to treat a group of itinerant people living on a caravan site in the Hackney area. Although the people in question were required to move to a different, unregistered site, in Tower Hamlets, the doctors who had earlier treated them continued to do so.

I recognise that homeless people have special problems in availing themselves of the services of family practitioners under these arrangements, but I understand from the City and East London family practitioner committee that it has not had any requests for assignment by homeless people.

The hon. Gentleman referred to the report by the City and Hackney community health council, which I have seen. There are matters in it which require longer study by the bodies responsible for services in the area, but it does not seem to me entirely fair for the report to say that the failure of single homeless persons to register is the fault of general practitioners. If the people concerned apply to the family practitioner committee they will be found a doctor, by assignment if necessary. I note that in one of the cases of particular difficulty mentioned in the report a privately run hostel sought help from the district management team, and a sympathetic doctor was found for them.

In part of the report, a person who was apparently refused by a number of doctors is quoted as saying that had he been seriously ill it would have been extremely difficult for him to "shop around" and find a doctor prepared to treat him, but the House will see from what I have just said that this is not the case. If he had needed immediate treatment, any NHS general practitioner in the area would have been obliged to provide it.

I want to say one more thing on this subject. I have a great deal of sympathy with people who find themselves homeless, but one way of helping them is to stress the contribution that they can make to their own well-being. They can apply to go on a list as soon as they arrive in an area, and not wait until they are ill. The doctor is paid partly on the basis of capitation and standing allowances related to the number of people on his list, whether or not they are receiving treatment, and it is only fair to a doctor that people who are living, even temporarily, in his practice area, and who are going to look to him for help when they are ill, should seek to register as soon as they can on arrival.

A forthcoming paper entitled "Primary Medical Care at Hostels for Alcoholics" demonstrates the major contribution that is and can be made to the care of homeless alcoholics by conventional general medical practice. General practitioners were found to visit no less than 97 per cent. of the 104 hostels surveyed, the majority of whose wardens were happy with the quality of service given.

I turn briefly to services at accident and emergency units of hospitals. Although it is true that we are constantly discouraging casual attenders at A and E departments, I am glad to say that in practice staff rarely refuse at least to examine, and often to treat, those who present themselves with minor complaints, particularly where it is clear that the patient has no general practitioner. It must be remembered that London A and E departments have a particularly burdensome problem here, not only because of homeless people but with a large student population and the ever-present holiday visitors.

Of course, the problem is not confined to hospitals with A and E departments. In spite of efforts to discourage the practice, by publicity and information, we are well aware that casual attenders will even present themselves at hospitals which do not provide a service for emergency cases. The department has suggested to hospital staff that in this eventuality, essential first aid should be rendered by such staff as are available, and the patient should either be referred to a general practitioner or to the nearest hospital with A and E facilities. I hope that it is clear from this that we have a humanitarian policy towards such patients.

The community health council booklet, and the hon. Gentleman just now, commented on the effects of closures of accident and emergency units on health care for the homeless. In the City and Hackney area there are no closures of these units, nor are there any closures of other types of hospital facility which have a particular bearing upon services for the homeless, such as orthopaedic units. Although there are 34 alcoholism treatment units in England and Wales, there are many other areas, such as Hackney, where alcoholics are admitted to psychiatric hospitals, and the psychiatric wards of general hospitals, as part of the total provision of services for alcoholism within the local community.

When closures of hospital departments have to be considered, I have no doubt that health authorities, assisted by community health councils, will have regard for the need to provide alternatives, including alternatives accessible to this group.

The Hackney CHC-CHAR document also raises the problem of proper arrangements when single homeless people are discharged from hospital after treatment. The hon. Gentleman also mentioned that in his speech. We have advised health authorities that the full benefit of hospital treatment may well be lost if arrangements for after-care are inadequate. Hospital staff are well aware of the importance attached to social as well as medical considerations when arranging for a patient to be discharged from hospital. They have been advised that a patient's "home circumstances" are a key factor in determining what after-care he needs.

One of the functions of hospital social workers is to ensure that people are not discharged to surroundings which will cause the return of or aggravation of their health problems. This is a matter of local knowledge about the day facilities, which I understand voluntary organisations for the homeless are increasingly providing for sick persons.

I shall write to the hon. Gentleman and give him further details of what the Government are doing, particularly about points to which I have been unable to reply. I have welcomed the opportunity given by the hon. Member to lay before the House an indication of what is being done, and what can be done, at a local level to help homeless people to gain access to health services. The way forward lies not in the creation of separate services but in looking at the need to improve entry points to the present services and discharge arrangements so that the existing arrangements of services meet the needs of the homeless.

Question put and agreed to.

Adjourned accordingly at half-past One o'clock.