Dr. Austin O'Carroll:

I thank Deputy Duffy. On the Housing First programme, the evidence that it reduces mortality is not huge but it would make sense that it would reduce mortality rates because we know that it improves mental health, it reduces suicidality and it reduces drug addiction. I have seen this myself. When people get into their own houses the level of drug use reduces and their mental health improves. The presumption is that if it has an effect on mortality it will not be immediate and that it will take place over a period of years. In other words, the longer a person is away from homelessness the less the chance of dying younger. It is key. During the Covid crisis we have seen the importance of accommodation to health. I have seen many cases of people in Housing First whose lives were very chaotic and who have since totally reduced their drug use and their mental health has improved dramatically. Housing First is definitely key in going forward.

On access to primary care, we should be fair here in that Dublin is probably one of the two best cities in the world for access to primary care for people who are homeless. I did my doctorate on the subject of why homeless people do not access primary care. I could wax lyrical on this for hours. The simplest way to put it is that our health system is designed for housed people. It is designed for people who can make appointments, have diaries and can keep slots. When people get appointments from the hospital, they actually receive them by post and can keep them because they have made a slot for them. Housed people are comfortable in sitting in waiting rooms and they do not feel excluded. They do not feel nervous about doctors or intimidated by doctors. They also care about their health because they have a future. One of the key determinants for people who are homeless not accessing healthcare is that they do not expect to live very long because they see so many people dying young. They ask, "What is the point taking good care of my health?" I do not know if the committee members are aware of Maslow's triangle of needs. At the bottom is food and housing, healthcare is quite higher up, and self-actualisation is at the top.

For people who are homeless, particularly if they are addicted to drugs, they are probably at the bottom of the pyramid. Their priorities are, first, to get up and feed their addiction, if they have addiction issues such as alcohol or drugs, and then they have to organise accommodation and food, so health moves way up the priority list.

I have only given the committee a few of the issues that affect why they do not access health primary care. That is why specialised services go to where they are and bring the services to where they are. Dublin is probably the one of the two best cities in the world in this regard and we should be proud of what we have. We also have fantastic secondary care services, with inclusion health models developed in St. James's and the Mater by Clíona Ní Cheallaigh and Tara Grogan. We have really good services. In particular, what we are suggesting is that they are particularly focused on State temporary accommodation, and we need to refocus them on private accommodation. The HSE is doing this at present so I know the issue is being addressed, as we speak. I hope that answers the question.