Dr. Fiona O'Reilly:

I am Fiona O'Reilly. I am joined by Dr. Austin O'Carroll and we are here from Safetynet Primary Care.

Safetynet Primary Care is a medical charity that aims to deliver the highest possible standards of health care to homeless people and other marginalised groups. Our network of services includes 20 clinic sites in Dublin, Limerick and Cork providing services to thousands of homeless and vulnerable people each year. Our direct services delivered in collaboration with the Health Service Executive, HSE, social inclusion and partner organisations, such as our colleagues here from Dublin Simon, include a primary care in-reach team in homeless hostels, a mobile health unit for rough sleepers, clinics for vulnerable migrants and a health and screening unit for vulnerable populations, including the recently relocated asylum seekers from Syria.

The link between homelessness and poor health is well established. Ms. Randall pointed out that homeless people have far worse physical and mental health conditions than the housed population. She pointed out also that poor health can lead to homelessness and that homelessness can lead to poor health.

I will draw on two examples from patients Dr. O'Carroll saw earlier this week. He saw Mary on Monday. She is a single parent in her 20s. She has been depressed recently and is not coping with managing household expenses. She failed one rent payment and is to be evicted this week. Peter is a young man whose drug addiction has gone out of control in the past three months since he went into a hostel. He had three overdoses in one week recently and needed to be revived with naloxone each time.

Dr. O’Carroll and myself conducted and-or analysed significant health surveys of homeless populations from 1997, which was conducted by Tony Holohan, and one we conducted in 2005. The one in 2013, which I made available to the members, was conducted with the Partnership for Health Equity. As a result of that significant research, we conclude that over time, through economic bust and boom, homelessness remains an unhealthy state. Of the 601 homeless people interviewed in Dublin and Limerick in the most recent survey, we found that almost the entire sample had either a diagnosed mental or physical health problem.

Ms Randall highlighted some of the important findings, but others are that over half reported a diagnosis of depression and half a sample had both a mental health problem and an addiction problem. I find it alarming that one third of respondents had self-harmed, three fifths have had suicidal thoughts and one in three reported having attempted suicide. Compared with the previous studies in 1997 and 2005, the recent study showed that the homeless population had more diagnosed ill health, more were treated with prescribed medication and more reported mental health diagnoses and treatment in 2013. We believe that is as a result of more services diagnosing disease rather than an actual increase in disease. Ill health is a constant feature of homelessness.

Services have improved. Medical card coverage has improved. The level of primary care and emergency department use has increased. We thought that increasing primary care access would decrease hospital admissions and presentations in hospitals but because there is such a high burden of disease, putting in place more services will just pick up that ill health. That has resulted in a higher number of onward referrals.

Ms Randall outlined the findings about addiction. It, too, has risen steadily over the 17 years to now become polydrug use. Rates of dangerous drinking have also increased, particularly among women. Drug and alcohol addiction associated with secondary health problems such as liver disease, dental problems and hepatitis C were also found to be elevated among those populations.

Recommendations are included, and we concur with the recommendations Ms Randall pointed out, namely, expansion of specialised primary care services; expansion of easy access to methadone treatment in primary care; improved access to appropriate mental health supports, including psychiatry; and the urgent establishment of interventions for homeless people in crisis in line with national suicide prevention guidelines, including a crisis house. Overall, we found that the health needs of the homeless are great and although much is being done, much more needs to be done, particularly in the area of mental health and addiction.

Safetynet Primary Care aims to provide health care for the most vulnerable in our society and to employ the most effective treatment. For homelessness, the most effective treatment is a move away from the homeless condition. Our services, therefore, seek to remove ill health, addiction and poor mental health as a barrier to exiting homelessness. However, that is not simply primary care as usual. For many very good reasons, typical primary care services are simply inappropriate or inaccessible for many homeless people and other vulnerable groups. Again, I point to a patient Dr. O’Carroll saw yesterday to demonstrate that homeless people with serious health problems often fail to attend the mainstream services for treatment. Dr. O'Carroll saw Julie, whose right leg was completely swollen from her foot to her groin for the past six weeks. She has experienced a deep venous clot in the past. It is highly likely that she has another. She knows that could fire off, block an artery and cause instant death. She has been referred to an accident and emergency department twice in the past six weeks but has not gone.

Services have to meet people where they are located. They need to be innovative, appropriate, accessible and, importantly, patient centred and delivered in a coherent and collaborative way aimed at moving the person out of homelessness. A heath strategy in isolation of housing will not succeed. One quick fix that would succeed in removing one of the barriers to homeless people's access to care and medication would be to remove prescription charges for homeless people.