26/01/2017 06:40 GMT | Updated 27/01/2018 05:12 GMT

Life - And Death - On The Streets

Demand for end of life care is rising as the population grows. Combine this dynamic with a reduction in funding, patients with more complex needs, and traditional methods of delivering palliative care increasingly under the spotlight.

For one audience, it could be argued, the traditional delivery of end of life care is a model that should have been addressed some time ago. The number of people sleeping on the streets increased by 30% between 2014-15. How do we ensure that those faced with end of life issues, who don't have a roof over their head, aren't marginalised even more at a time when they are even more vulnerable? How do we best provide some of the most complex clients with adequate access to physical and psychological support?

According to Homeless Watch, for many in the homeless community, early life experiences are shaped by a difficult upbringing, whether this is related to sexual, physical or substance abuse, or even living in relative poverty with a lack of opportunity. As a result of these experiences, homeless people are more likely to have a combination of chronic physical and mental health issues and substance misuse problems, which can often mean that they require some of the most complex palliative care. According to a report by Marie Curie, in partnership with St Mungo's, the average life expectancy for homeless people is 55 compared to 81 nationally. Yet homeless communities continue to struggle to access appropriate health and social services.

A lack of education around this hard to reach community means homeless people are often admitted to hospital in times of medical crisis, as it is perceived to be the best place for them. However, for those who have historically avoided engagement with healthcare professionals, most likely because of a negative experience, being treated for a terminal illness or indeed dying in hospital can be alienating and uncomfortable. They often discharge early. The medical personnel they come into contact with have been trained to treat the symptoms, and are unlikely to have the time or the training to want to broach the sensitive subject of how their patient wants to die.

Even if the patient is discharged to a shelter or hostel rather than the street, therein lies another complex series of problems. Hostels are generally geared around the premise of 'recovery', offering a short term respite for those that have been discharged from addiction recovery units. Staff will, again, be inexperienced and untrained in dealing with a client who requires much more complex care, psychologically and physically. In turn, this can be an intensely lonely place for the client, whose circumstances don't afford the luxury of discussing and planning for their death: how they want to be remembered and where, or any possible reconciliation with family or old friends. Pastoral or spiritual care is incredibly helpful during this phase and, again, there may be little option for this to be offered.

What might be called 'the seldom heard' has been one of the audiences considered by the Fit for Future review which is being led by St. Margaret's Hospice in Somerset, and is designed to assess how end of life care models can be adapted to be able to cope with the changing dynamics of our society. One of the key challenges highlighted by the initial report is the need for accessibility and equality in an increasingly fractured society.

A charity with a £10m turnover, we care for over 3,200 people each year in our hospices, with respite care and in the community. One in three people in Somerset will use our services in their lifetime. Earlier this year, we were awarded an outstanding accreditation by the Care Quality Commission (CQC) in four of five qualifying areas: a UK first.

After NHS funding, we still need to raise over £7.5m to provide care which is 100% free to patients and their families at the point of service. To support our fundraising efforts, we also operate 36 retail outlets and a wide range of fundraising events and activities, but it's important that we look at ways in which we can also streamline palliative care to make efficiencies.

Across the board we recognise the need for greater emphasis on education and shared learning amongst care professionals in the community; where more people should be cared for given the increasing pressure on both hospitals and hospices. This isn't just a homeless issue, but also one for an increasingly multicultural society, for whom our traditional approach to dying may not be culturally acceptable. There has already been some tremendous progress made by the Kingsway Pathless Homeless team in London but it is still too localised. I hope some of the work we will be doing, in partnership with others, will help take these, and other similar initiatives, further.