Rough sleeping is deadly. We meet the NHS outreach workers trying to save lives on the street

“Never got any help anywhere,” James [not his real name] tells me. “I’ve gone up and down the country. It’s been the same, no help.” We’re sitting on the floor in the entrance to Woolwich Tesco, nestled between the trolleys and the automatic door as shoppers stop to give James change. Grey is coming through in his short beard. He sits with a coat on his knees, rubbing his hands.

Gemma Scott, a clinical practitioner on the Rough Sleeping and Mental Health Project (RAMHP), run by Oxleas NHS Foundation Trust, has bumped into James by chance on her rounds around the outer reaches of South London. She’d been texting him the night before about an appointment, making sure everything was on track. Now she’s asking about how things are going, offering to help him change GP if he gets the place.

James is anxious about a flat viewing in an hour or so, the first time in a decade he’s been offered a proper place to live. His life has been a cycle between prison and the streets, leading to here. “Sorry, I’m bricking it. Ten years I haven’t had a place,” he says.

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“It’s not a good day. I’ve lost my squidgy,” he continues, adding that he first realised he had mental health issues over 25 years ago, but with a lack of help he simply learned to live with it. “I can go get you one now,” Scott offers, looking them up on her phone. “I love my squidgy balls,” James replies, and off Scott goes into Tesco.

“First time I’ve had proper help,” he tells me. “It feels mental. It’s scary.”

It’s only the third time James and Scott have met. She’s been helping him with his meds, but he doesn’t want to get into too much detail before the housing appointment. It’s the first time he has completed his probation, and Scott led the efforts to keep him in the borough, mobilising a team of professionals. The work starts with these meetings on the streets.

I’ve been accompanying Scott on her day doing outreach. James is just one of the people she’ll encounter – some scheduled, some not. For the past three years, Scott has been working in this new unit, an unusual team which goes out onto the streets and helps rough sleepers with their mental health. Her job is to pull services together to meet the healthcare needs of rough sleepers. Being within the NHS means she can help in ways others can’t – less resistance, better evidence to help them with. Even having an NHS email can open doors. “It shouldn’t be like this, but sometimes clients need someone next to them who is a professional,” she tells me. “People feel less on their own.”

Homelessness and health have long been thought of as linked problems – poor health causing homelessness, homelessness causing illness, a cycle which continues until, on average, somebody experiencing homelessness dies 30 years early.

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In Britain, initiatives like Scott’s NHS unit are at the forefront of tackling these linked problems. Yet they can often be maverick teams without a stable future – a piecemeal, patchwork landscape which experts say is putting lives at risk.

“Incredibly committed individuals are setting up services and working in them, but they are doing it against the odds,” says Dee O’Connell, director of policy and programmes at Pathway. “Some of these services are successful in getting mainstreamed into business as usual in the NHS, but it is more often the case that they limp along on short-term funding and need to continually make the case for their existence.”

Failure to make these more stable is having profound consequences. “What is at stake is people’s lives,” says O’Connell.

Yet there is an opportunity. On one hand, Keir Starmer’s government has pledged to halve rough sleeping. On the other, 2025’s NHS 10-year plan champions a new approach to healthcare, bringing it out of hospitals and into communities. Homeless health teams believe they are the future, holding an answer to these puzzles – but they are fighting for a future. In the meantime, homelessness keeps cutting lives short.

Mario Fonseca had been working as a plumber and studying towards further qualifications, managing his chronic health conditions. Then, in 2019, neuropathy – severe pain in his legs – stopped him from being able to work. Fonseca had been in the same flat, above a hairdressers in London, for almost 20 years. But as the pandemic hit, his landlord sold the flat without him knowing. Within a couple of months, the new landlord was trying to evict him.

He didn’t know where to turn – Citizen’s Advice were little help. But then Fonseca remembered a number someone at the Royal Free Hospital, where he went for medical appointments, had given him. An hour later, he was in contact with the support hub run by the Royal Free Charity.

Fonseca believes homelessness would have killed him. His doctors agreed. “I didn’t have a plan,” he says. Without help, “the guys from the court would probably come and kick me out of the property”.

Set up to offer wider support, including housing and homelessness, for patients suffering long-term health conditions, the hub brought help within the other care Fonseca received. Like the Oxleas team, it’s taking a wider view of what’s needed to help patients – and it says over half of its clients believe it helped them to stay out of hospital for longer. 

The NHS, the charity says, does little to help with the issues in somebody’s life that could undo the medical care it had provided.

By the Royal Free Charity’s own statistics, the hub helps over 500 people a year, manages to stop its clients falling into homelessness, and prevents harm amounting to a value of £5.8 million.

“When I got through that door, I felt human again. Even if things don’t go the right way, there’s someone there to tell you it’s going to be OK,” says Fonseca.

The eviction plunged him into uncertainty. When he contacted the support hub, he hadn’t been given a formal eviction notice. By the time a section 21 notice arrived, the adviser at the hub told him to stay put. He was awarded “priority need” for housing by his council. But soon a writ was delivered by a bailiff, saying he’d be evicted in September 2024.

As Fonseca focused on staying alive – the pandemic made his health worse, and he spent two weeks in hospital – the advisers at the support hub managed the bureaucracy. Without an address he worried he would be unable to get medication. “My HIV medication, I depend on that forever, for the rest of my life,” says Fonseca.

With an eviction looming over his head, he struggled. “I couldn’t do anything. It was a nightmare, I couldn’t look after myself normally,” he says. “I was desperate.” When the stress of the situation brought panic attacks, his advisers were able to refer him to a psychiatrist. 

Days before his eviction date, his advisers’ work with the council paid off – he was offered temporary accommodation. He is now living in permanent accommodation, still seeing a specialist for the mental health issues brought on by the housing insecurity.

“I cannot change that, but I feel I’m not gonna fall. The past two months I started feeling more relaxed,” he says.

‘Some other services think what we’re doing is dangerous’

Before Scott took me out, we sat in the small office in the Erith Health Centre which serves as the RAMHP team’s headquarters, a Tetris grid of four desks and accompanying chairs, a cupboard full of biscuits and chocolate. Scott and colleague Maz Nazzal, a senior clinical practitioner, are explaining how it all works.

Health services for homeless people are under pressure. Three quarters of staff reported rising demand, according to research from Pathway, while just one in four said their services had secure, long-term funding. Nearly all staff believe missed opportunities in care are causing harm to patients.

After the initial trial, Nazzal and Scott’s project had funding for two years – meaning they are now on the hunt for long-term cash. There is also a battle against other arms of the state.

“In certain quarters of housing services, particularly, is that reluctance to accept there is a rough sleeping problem in the local authority. Some local authorities seem to be in denial, unfortunately. If you want to address a problem, you need to accept the problem in the first instance,” says Nazzal, who argues that once a problem is acknowledged, it needs resources – something councils are desperately short of.

“We tell them in our meetings, that’s what we’ll have to do, we’ll have to consider legal routes. They don’t appreciate it, but it’s a last resort,” Nazzal says.

The work is not always smooth. After we leave the office, Scott takes me to Eltham High Street, where she searches for a client. He’s not in his usual spot – a shelter opposite the entrance to Lidl, or in other places Scott looks. There is no fixed appointment, instead people are given a rough time to meet. She tries calling him, it rings out. Scott has already seen him this morning, but wants to see how an appointment went. “Hello, I’m from outreach,” she says as she stands outside the shelter for the second time. He’s not there.

This isn’t unusual. Sometimes Scott might have to climb over fences to get to people, but missed appointments aren’t a problem. They’ll even smooth things over with other services if an appointment is missed.

“Some other mental health services think what we are doing is dangerous, but I don’t see it like that at all,” she says.

Meeting people where they are might mean taking them out for pizza, chatting for the best part of two hours. If they can’t reach someone, they might think about how they can make it easier. Perhaps they’re simply the wrong person for the job – another member of the team might connect better.

“The whole idea is that, unlike secondary mental health services, our availability is dictated by the service user. It’s not us dictating to them,” says Nazzal.

Fixing the patchwork

The Labour government are attempting to overhaul the NHS. The 10-year plan, unveiled last year, details how cases will shift from hospitals into communities, aiming to relieve the burden on hospitals. In its ‘Neighbourhood Health Framework, the government argues that most people want health and care services as close as possible to where they live.

“All of those things the government says it wants to see in neighbourhoods, is what specialist homeless and inclusion health services have been doing for years,” says O’Connell. But as the big wheels turn, she warns homeless people – and the moment of opportunity – may be lost. 

“My worry is that there is nothing at all coming out from the government that is pointing to the needs of people facing homelessness in the neighbourhood health space.”

The challenge, then, is how to turn the islands – Nazzal and Scott’s team and the support hub which helped Fonseca – into a continent. O’Connell believes a range of changes can achieve this: as well as funding for specialist teams like these, there should be an end to hospitals discharging patients onto the streets, the NHS should begin formally recording housing statistics of patients, and the government should make homelessness part of its neighbourhood plans.

It isn’t a zero-sum game, argues O’Connell. “It’s wrong to think of it as being a trade-off between people who are at the worst end of health inequalities and the rest of the population,” she says. 

Progress, however, is not linear. In March, London’s only detox unit for those experiencing homelessness was marked for closure, with the government saying rising costs made it unaffordable “within existing funding” – something Big Issue founder Lord John Bird said was a “short-sighted cost-cutting exercise”.

Sitting on the floor in the entrance to Tesco, drinking a hot chocolate as Scott returns with the toy she promised, James recounts his story – a lesson in the individual cost of homelessness. And he tells Scott: “You’ve done a lot more for me than anyone else.”

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