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Off balance

February 12th 2018

This is the full version of Matt’s article for the Pavement magazine – theme suicide - March/April issue (#113)

While empty apartments are rising on every last inch of land in London, the cracks in society are getting wider. Although the voices for change are getting louder, still more of us are falling through those cracks. We feel this shift and register the balance is off, now the Samaritan’s recent report Dying from Inequality (2017) has revealed the mortal harm of this injustice.

The report finds that areas with higher social and economic deprivation tend to have rates of suicide two to three times higher than the most affluent areas. While it may come as no surprise that living in poor conditions facilitates human misery, this report shows how austerity has left the most vulnerable at greater risk.

The risk of suicide changes at times of economic crisis. During the 2008 recession, suicide rates rose significantly across the UK. This shift in the economy, with rises in unemployment and cuts to public services, caused waves of instability throughout communities, and for individuals, which can still be felt a decade later.

Working-age men were more vulnerable to the effects, facing “the threat or fear of home repossessions [and] job insecurity,” produced by economic uncertainty.

The shattering loss of a home or a job severs social ties and breaks up support structures, key protective factors against stress, leaving the individual more isolated and at greater risk. Those already on the edge were hardest hit, as the risk of suicide is amplified if a person is already experiencing multiple negative life events, such as poor health, unemployment, poor living conditions and feeling socially isolated. With increasingly limited access to services and support, those in more socio-economically disadvantaged circumstances were left more vulnerable.

These same circumstances which increase the risk of suicide – low income, debt and unemployment – are also recognised by charities such as Shelter as being among the structural causes of homelessness. While suicide rates of homeless persons are difficult to determine, a recent publication by Pathway, a homeless healthcare charity, has found mortality rates to be significantly higher in the homeless population compared to the housed population, with “injury, poisoning, and external causes” at elevated levels.

During a recent team meeting at a Major Trauma Centre in London, Alex Bax, Chief Executive for Pathway, found that of the “32 patients on the list, seven were suicide attempts”. Knowing that nearly a quarter of homeless patients admitted to the Centre had attempted suicide related injuries, Bax asks, “What’s leading people into a position of being so desperate that they kill themselves? What is it about our social structure?”

Echoing other experts in the field, Bax states Pathway are “seeing the impact of austerity” on wellbeing. “The benefit system is becoming harsher, harder to deal with and people are given less money. It’s difficult accessing what’s available; there are more barriers, and there is more gatekeeping.”

With cuts to mental health services the housed population face longer waiting times for assessment and treatment, but for the homeless population accessing these services are fraught with further difficulties.

Stan*, Pathway’s Experts by Experience Lead, has observed “two huge pitfalls for someone who is homeless” - the lack of a fixed address and dual diagnosis.

Gaining access to healthcare services, particularly GP practices, has historically been problematic for those in the homeless population without a fixed address or forms of identification. It often forces people to turn to A&E Departments when their health condition has worsened and become more difficult to treat. Additionally, as many in the homeless population are not fixed to a local area, they are more likely to slip between healthcare service providers, further preventing access to treatment.

At a time when there is evident need for more support, drug and alcohol services are also being slashed, even though drug related deaths are at a record high according to the Office for National Statistics.

Cuts to these services exacerbate the difficulties in treating complex conditions such as dual diagnosis, or a mental health problem combined with problematic substance use. There is currently no agreed upon point of contact or treatment for dual diagnosis, with mental health services and drug and alcohol teams arguing the initial responsibility for treatment lies with the other.

It is commonly known that substance use is employed as a coping strategy by some individuals to manage existing mental health problems. So while services are quarrelling over who should take responsibility, potential patients are left to self-medicate, further entrenching existing mental health and substance use problems.

Not denying the good intentions of healthcare professionals in both services, without joined-up thinking this fragmented system of support leaves the individual knocking at the doors of bureaucracy and at a greater risk of harm.

It has become increasingly clear that austerity has deeply fractured our society, severing support structures and leaving the most vulnerable at risk.

The blatant social harms of government policy are being exposed. As Bax rhetorically asks, “If you put people under chronic stress and take their money away, what do you think might happen?”


How to help

New solutions are necessary to bridge the ever-widening chasm between us, to aid reconnection and relieve suffering. For Bax, there are several protective factors that keep people alive during times of despair, “A sense of purpose, agency, and having some human relationships. That’s what people live for. Being alive is something other than just not being dead”. For the team at Pathway this is not a tired soundbite, but a philosophy that has become a tried and tested practice with the potential to improve lives. Pathway’s Experts by Experience program is one such example. It’s a voluntary service, led by Sam* that allows those with experiences of homelessness to “use their lived experience to help shape homelessness services rather just be a "user" or “recipient" of a service. So, it's a proactive rather than a submissive relationship”.

Through training and volunteering, with a community of other workers, the individual regains purpose and direction and finds a voice to create positive change. This program helps rebuild the confidence and skills which are often lost during the experience of homelessness.

This peer approach is also used by the charity, Groundswell, who conducts peer-research, or research projects carried out by those with lived experience of homelessness. Peer-researchers have a close connection to, and nuanced understanding of, the topic concerned, allowing greater insight and access to those who are “hard to reach”.

Groundswell’s peer-research study, More than a Statistic, has further highlighted the difficulties registering and making use of a GP practice as a key barrier to healthcare. The findings of this study have led to the production of the My Right to Healthcare card, a document to be used by those experiencing homelessness to improve their access to services and remind staff at GP practices of the NHS England registration guidelines. Despite the historic difficulties accessing services, these guidelines state that a fixed address and identification are not needed to register and immigration status does not matter to receive treatment at a GP practice. Over 40,000 My Right to Healthcare cards have already been delivered to shelters, day centres and food banks across London, and they are available to download and print from Groundswell’s website. Another 20,000 were printed in January 2018.

Ahead of this curve are the hard-hitting homeless peoples’ theatre group Cardboard Citizens, who have been making life-changing theatre for 25 years. Cardboard Citizens invite those who are experiencing homelessness, or who have lived experience of homelessness, to have a voice by creating Forum Theatre. Forum Theatre empowers the actors and engages the audience by asking the public what could be done differently in a scene to create a more positive outcome. Through this dialogue between actors and audience a new possibility emerges: change is possible. Their recent production, Cathy, provided, “a timely reflection on the social and personal impact of spiralling housing costs, gentrification and the challenges of the forced relocation away from London”. At the end of each performance the audience were asked to create laws that could be implemented to positively change the challenges the protagonist was facing. Using feedback “from audiences across the country” these “Cathy Laws” were then presented at the Labour Party conference in September 2017.

Such a wide reaching and yet direct approach has the capacity to bring about the social change our fragmented system needs. The work of Cardboard Citizens should be loudly applauded and recognised for providing the “purpose”, “agency”, and “human relationships” Bax and his team at Pathway prescribes.

Cardboard Citizens are not just a theatre company, but a voice and a community for those who are without one.

So, while empty apartments are rising on every last inch of land and the cracks in society are getting wider, we have to shout. At the moment it is only our voices for change that will help stop us from falling through.

 •Read the full report, Dying from Inequality on

 •More about Pathway

 •Life changing theatre from Cardboard Citizens, see

 •More about Groundswell’s campaigning health and homeless work at


In a nutshell

1 Suicide attempts rise when times are hard

 • Triggers include job insecurity and fear of home repossession

 • Having to move breaks up people’s own support structures

2 There’s fragmented health support

 • Poor health, and pain, may also be factors

 • As wellbeing falls, mental health services are even more important

3 Cuts to public services and poor living conditions remove safety nets

 • Homelessness or a lack of an address make support less likely

 • Living in a more disadvantaged area puts you at a two or three times higher risk of suicide than more advantageous areas.

4 Lack of joined-up thinking adds to the problems

 • Drug and alcohol may be used as self-medication. But these services have been slashed

 • Dual diagnosis can make help even harder to get

5 Positive change is possible

 • First be suicide safe – survive the crisis

 • Find a community that’s true to you

 • Make connections, train and volunteer


Mar/Apr 2018



Off balance

GP will see you

Public shift

Numbers up

Only in Scotland

News in brief, March–April 2018

Why suicide?

Off balance

Everybody hurts

Not a number

First person

You are not alone

I feel good


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