While the COVID pandemic has hit everyone hard, for those who are homeless the challenges have been even greater, as Senior Inspector Gail McDonald tells us.

Usually, you take up a secondment expecting you’re going to be working somewhere else for a while and you mentally prepare yourself for the changes. What you don’t expect is what happened to me. After 14 years working in Homeless Health Services, towards the end of last year I was offered a two year secondment with Healthcare Improvement Scotland as a Senior Inspector on the Adult Support and Protection (ASP) Inspection Programme. And I thought that would be it for the next two years.

But after just four months, my old colleagues were unexpectedly seeing my face again as I returned to my substantive post because of the global pandemic. It was certainly something neither me nor my colleagues could ever have predicted!

Making sure the support is there

With my old role as Team Lead for Occupational Therapy and Mental Health Teams already backfilled, there was no obvious place for me to slot into at first, but I was happy to return to the work I love, with many valued colleagues, and I was willing to pick up whatever I needed to. Ultimately, I took on a role as Occupational Therapy and Admin Team Lead and had a role in the service recovery and social distancing planning in the building.

My first days back were a bit odd, trying to deal with the sudden shift from one role to another. But in many ways we were all in the same boat: it was the early days of lockdown so the atmosphere and environment was one of uncertainty, change, but most of all of support. Staff from all teams were really pulling together to ensure the delivery of essential services for homeless people was maintained. There was a focus on mental health care and treatment, urgent General Practitioner services, wound care, needle exchange, sexual health and opiate replacement treatments. The city had already undertaken emergency action to accommodate any individuals who were rough sleeping or in night shelters where isolation and social distancing was not possible, including individuals with no recourse to public funds. This was to ensure people could keep safe and comply with isolation and ‘lockdown’ recommendations. People were primarily accommodated in city centre hotels with food parcels or meals being delivered daily.

The need to maintain contact

In the initial weeks the expectation was that those who were homeless would be disproportionately affected by COVID-19. This population have poorer health, live in more communal-type settings and are arguably less able to follow some of the restrictions of lockdown due to health and social functioning issues. The obvious conclusion, therefore, was that the death rate would be higher. Service delivery planning initially became about reducing and restricting contact for the safety of service users and staff alike, with the exception of the mental health team whose contact remained consistent due to the level of vulnerability of their service users.

However, it soon became clear that the risks of no contact with service users outweighed the risks of COVID- 19. Individuals who are homeless are dealing with a whole variety of issues beyond and arguably more severe than COVID-19. Day centres and visiting supports were closed, so social and community supports were significantly reduced. We had to set up alternatives quickly, ranging from daily visits or phone calls to weekly or a minimum of monthly face to face contact. There was a focus on assertive outreach and those service users who had no phone were issued with pay as you go mobiles. This low cost intervention proved to be hugely valuable to both service users and staff. Service users valued the means to stay in touch and have continued engagement. Health and social care interventions increased due to staff being able to contact them. Even service users who had been typically reluctant to engage with health were open and inviting increased contact – a real indication that the situation was taking its toll on how people were feeling.

Breaking down barriers

In general the situation in relation to COVID-19 strengthened the need and justification for a health service with reduced barriers and an assertive outreach approach. Much of the work was adapted or an extension to what already existed. The addiction service probably experienced the most significant learning curve as they had to work out how to continue to support those undergoing opioid replacement therapy, such as treatment with methadone. For most people, the answer was to give them longer prescriptions and more take home doses, rather than their usual daily dose at a pharmacy. But this was only undertaken after a risk assessment had been carried out. We did, of course, have a lot of service users who went through very hard times due to COVID-19. Some were not allowed back into their accommodation as they were not following lockdown rules.  Drug debts increased for some, as there were far fewer opportunities for begging. Treatments for conditions like hepatitis C were suspended.  Contact with children was limited and rights to have access reviewed were suspended due to courts not sitting. And, just like the rest of us, there was the sense of increased isolation from family and friends.

There was undoubtedly an increase in homeless presentations over this time, but with registered social landlords not accepting referrals and there being virtually no movement ‘out’ of homelessness into permanent accommodation, a huge block was created in the system. This will impact homeless people for months beyond this initial lockdown, and the demand on all the additional support services is continuing to grow.

A learning experience

While what I’ve seen for individuals affected by homelessness in the past few months has been some of the toughest in my career in the past few years, I’ve also learned a lot. I’ve seen first-hand how service delivery can adapt and evolve in response to a unique situation. I’ve seen a renewed commitment to challenging structured, non-flexible health care delivery. And I’ve seen the willingness and supportive nature of most staff when push comes to shove.

It’s been intense, and it’s taken me a couple of weeks to wind down from, but I’m glad to be back at Healthcare Improvement Scotland and looking forward to putting what I’ve learned to good use in the Adult Support and Protection (ASP) Inspection Programme.

More information

Visit the Healthcare Improvement Scotland website for information on our response to COVID-19.