Homeless patients have said they feel either excluded or discouraged from attending health services and medics have described difficult interactions with some homeless clients, including being lied to over prescription drugs or fearing violence if they refuse to provide certain medication.
The findings are included in a comprehensive new study led by Dr Austin O'Carroll of SafetyNet Primary Care, who is also the clinical lead on the Covid response when it comes to those experiencing homelessness.
The report is entitled Conversations of exclusion: An ethnographic exploration of doctor-patient interactions that result in homeless patients being excluded from the healthcare service, and was carried out over 13 months in Dublin with three services for homeless people and an outreach service for rough sleepers.
It also involved focus groups of hospital doctors and homeless people, and 47 semi-structured interviews with homeless people.
Four "Conversations of Exclusion" were identified. One was the "benzodiazepine conversation", whereby homeless people said doctors reacted angrily or became annoyed when asked for benzodiazepines.
According to the study, "For participants, these tablets were extremely important for surviving the rigors of homelessness", such as anxiety and insomnia, but some doctors were quick to rule them out - "Ah he’d say 'whatever you do, don’t start asking me for Benzos'," one homeless person said.
The study also found that doctors who don't want to provide the drugs over fears it is feeding an addiction are fearful of a physically violent response if they refuse.
"They’re not leaving until they get it..demanding this off a doctor or that off a doctor and the doctor hasn’t got time and they’re getting angry then," one doctor said.
Some homeless people suggested that doctors were sharing stories about a patient's use of benzos and sometimes the result was that the patient would simply stop attending.
"The Mistrustful Conversation" was another barrier identified in the report.
One doctor said: "So I felt very annoyed that someone that I had treated with respect was lying to get the prescription...You know you do your best, you treat someone with respect and then they turn around and they treat you like that. It will probably make me more suspicious, less trusting."
But for some homeless people, "telling a lie was essential to get their needs met". According to one service user: "you do manipulate, you lie and you do coerce when you want that drug."
Another barrier was health professionals blaming patients for causing their health problems, with some clients saying there was a class element and one referring to their doctor speaking in Latin.
Finally, the "Assertiveness Conversation" was highlighted as a problem, where homeless people were sometimes unable to make their point without it being seen by others as aggressive.
The authors recommend alternative approaches for doctors and the use of different language to explain their decisions, resulting in a "Conversation of Inclusion".
- You can read the full report here.