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