Fairer Practice: palliative care for people with experience of homelessness

Publication date: 29 May 2026

For many patients, dying at home is not an option. The Scottish Deep End's Dying in the Margins work1 highlights how many patients live in substandard housing, with damp, high heating bills, or no room for hospital beds or medical equipment. 

My practice saw several medically unexpected - but not surprising - deaths over the last year. So, as I study for the European Certificate in Essential Palliative Care, I’m thinking of those patients who do not have a home - or a house - to go to at all. How can we use the Fairer Practice toolkit to meet the Daffodil Standards for all our patients?

Nine to twelve per cent of rough sleepers are aged 55+2, and the problems of homelessness cause accelerated aging3.  For those sleeping rough, the mean age at death is 46 for men, and 43 for women4. 

Marginalised people are given less chances to discuss care planning5. These decisions may feel abstract when they are struggling to get through the day. While hostel staff and support workers are arguably best placed to discuss advanced care planning6, they may lack the skills and confidence to ask for clinical support.  Meanwhile, clinicians and health systems are rarely alert to signs of premature frailty.

After palliative needs are spotted, the health barriers for people with experience of homelessness persist.  Apart from systemic healthcare barriers, many carry profound personal and systemic trauma.  Complex traumas, relational needs and avoidant attachment styles put people at higher risk when engaging with palliative care7. Loss of autonomy may be more feared than death itself8.  

Post-traumatic stress symptoms can resurface towards the end of life, correlating with delirium, dyspnoea and emergency admissions9.  Trauma may have eroded access to informal carer support.  Emotional distress adds to total pain10. 

The ‘equity turn’ in palliative care aims to mitigate this11. Feldman’s Stepwise Psychosocial Palliative Care Model12 shows what can be done to give trauma-informed support - without discussing or knowing the original trauma(s).  Toolkits13, networks14 and local services are building a community of practice focused on welcoming and supporting people with palliative needs. Given lack of community care often means expensive emergency admissions, early evidence suggests specialised support gives value for money as well as improving care15. 

So, what can we do in primary care?   

Building links with local services, and trauma-enabled care with continuity, can build relationships before patients need palliative support. Non-clinical workers who know the patient well can be empowered to notice worsening health, lead on care planning, and liaise with us for medical advice6. 

But the first steps are finding and seeing these people.   

  • Do our teams code for insecure housing?   
  • Can we be flexible for walk-ins and late arrivals?   
  • Do we call people or their support workers when they do not arrive?   
  • Have we empowered shelters to reach out with concerns when patients’ health is worsening?

Next steps 

One Small Step Today: Welcome patients with no fixed address or ID with posters from Doctors of the World. 

CPD 

Toolkits 

  • The Fairer Practice toolkit contains evidence-informed actions for your practice to improve outcomes through access and targeted continuity.  Our working group is working with the RCGP and Marie Curie Daffodil Standards team to build palliative care actions into the toolkit, so watch this space.   
  • If you’d like to spot patients who need support now, The Homeless Palliative Care toolkit can get you and your team started. 

The Vision In Practice

Communities 

  • Upcoming Fairer Practice webinars will explore how to see these patients in our practice’s population data, and discover which patients are in most need of targeted support.  Keep an eye out on the RCGP Events page or join our mailing list and Whatsapp group for future dates! 
  • Pathway has a community of practice around palliative care for people experiencing homelessness, which hosts online monthly meetups.   
  • I hope to see you at our Manchester Fairer Practice conference on June 24th. 

References 

  1. University of Glasgow End of Life Studies Group. Dying in the Margins [Internet]. Gla.ac.uk. 2019. Available from: https://www.gla.ac.uk/research/az/endoflifestudies/projects/dyinginthemargins/#studybackground&nbs
  2. Mantell R, Hwang YIJ, Radford K, Perkovic S, Cullen P, Withall A. Accelerated aging in people experiencing homelessness: A rapid review of frailty prevalence and determinants. Frontiers in Public Health. 2023 Mar 16;11. 
  3. Age UK. Older homelessness (England) [Internet]. 2019. Available from: https://www.ageuk.org.uk/siteassets/documents/policy-positions/housing-and-homes/ppp_older_homelessness_england.pdf ;
  4. Office for National Statistics. Deaths of homeless people in England and Wales - Office for National Statistics [Internet]. www.ons.gov.uk. 2019. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsofhomelesspeopleinenglandandwales/2019registrations ;
  5. Richards N, Quinn S, Carduff E, Gott M. Dying in the margins: Experiences of dying at home for people living with financial hardship and deprivation. SSM - Qualitative Research in Health [Internet]. 2024 Jun 1 [cited 2024 Apr 9];5:100414. Available from: https://www.sciencedirect.com/science/article/pii/S2667321524000234 ;
  6. Tackling Inequalities in End of Life Care for Minority Groups VCSE Health and Wellbeing Alliance Project Group. Care committed to me. Delivering high quality, personalised palliative and end of life care for Gypsies & Travellers, LGBT people and people experiencing homelessness: a resource for commissioners, service providers and health, care and support staff. [Internet]. London: Hospice UK, on behalf of the Tackling Inequalities in End of Life Care for Minority Groups VCSE Project Group.; 2018. Available from: https://www.hospiceuk.org/publications-and-resources/care-committed-me ;
  7. Sànchez-Julvé C, Viel-Sirito S, Limonero JT. Attachment at the End of life: a systematic review. Palliative and Supportive Care [Internet]. 2025 [cited 2025 Oct 11];23. Available from: https://www.cambridge.org/core/journals/palliative-and-supportive-care/article/attachment-at-the-end-of-life-a-systematic-review/D4EFB2A60B6A56C1BD9A5D059F18714E ;
  8. Webb WA, Mitchell T, Snelling P, Nyatanga B. Life’s hard and then you die: the end-of-life priorities of people experiencing homelessness in the UK. International Journal of Palliative Nursing. 2020 Mar 2;26(3):120–32.
  9. Bickel KE, Kennedy R, Levy C, Burgio KL, Bailey FA. The Relationship of Post-traumatic Stress Disorder to End-of-life Care Received by Dying Veterans: a Secondary Data Analysis. Journal of General Internal Medicine. 2019 Dec 2;35(2):505–13. 
  10. Johnston N, Chapman M, Gibson J, Paterson C, Turner M, Strickland K, et al. Re-living trauma near death: an integrative review using Grounded Theory narrative analysis. Palliative Care and Social Practice. 2024 Jan;18. 
  11. Smith KA, Stajduhar K. Using relational ethics to approach equity in palliative care. Palliative Care and Social Practice. 2024 Jan 1;18. 
  12. Feldman DB. Stepwise Psychosocial Palliative Care: A New Approach to the Treatment of Posttraumatic Stress Disorder at the End of Life. Journal of Social Work in End-of-Life & Palliative Care. 2017 Jul 3;13(2-3):113–33. 
  13. Homeless Palliative Care Network. Toolkit [Internet]. Homeless Palliative Care Network. 2026. Available from: https://homelesspalliativecare.com/toolkit ;
  14. Pathway. The Faculty for Homeless and Inclusion Health: Palliative Care [Internet]. Pathway.org.uk. 2025. Available from: https://www.pathway.org.uk/issues/palliative-care/ ;
  15. St Ann's Hospice, Garnett J, Brophy N, McIntyre H. Evaluation of the Homeless Palliative Care Service at St Ann’s Hospice for the Big Lottery Fund [Internet]. 2024. Available from: https://moyacole.org.uk/homeless-palliative-care-service-report/ ;

About the writers

DLB

Dr Lindy Bolzern

Dr Lindy Bolzern

Dr Lindy Bolzern - First5 lead for the RCGP's Fairer Practice community. Dr Lindy Bolzern CCTs in June and works in Greater Manchester.

She is a plenary speaker at the Fairer Practice conference. She is passionate about primary care support for persistent pain, persistent physical symptoms, and complex PTSD.