Doctor–patient interactions that exclude patients experiencing homelessness from health services: an ethnographic exploration

Background: People experiencing homelessness have poor health indices and poor access to health care. Their health service utilisation (HSU) is typified by: late illness presentations; poor attendance rates at appointments; low usage of primary care services and outpatient departments; and high utilisation of emergency departments and inpatient services. Why people experiencing homelessness have these particular HSU patterns is poorly understood. Aim: This research sought to explore barriers to health service usage for people experiencing homelessness. Design & setting: The authors conducted critical realist ethnography over 13 months in Dublin with people experiencing homelessness at four purposively chosen sites (a food hall, a drop-in centre, an emergency department, and an outreach service for rough sleepers). Method: Ethnographic research was supplemented with focus groups of hospital doctors and people experiencing homelessness, and with 50 semi-structured interviews with people experiencing homelessness. The epistemological framework was critical realism. Results: One of the factors identified in the research as contributing to the HSU pattern of people experiencing homelessness was recurrent interactions between health professionals and patients, whereby patients were either excluded or discouraged from attending health services, or self-excluded themselves from services. These interactions were described as ’conversations of exclusion’. Four such conversations were described: ‘the benzodiazepine conversation‘; ‘the mistrustful conversation‘; ‘the blaming conversation‘; and ‘the assertive conversation’. Conclusion: There are certain recurrent interactions between people experiencing homelessness and doctors that result in the exclusion of people experiencing homelessness from health services.