The people the health system walks past

I moved to Sydney from Canberra last year. I expected the beautiful harbour, the crazy traffic and the exorbitant rent and housing prices. Nothing prepared me for what I saw in my first few weeks walking through the city on my way to work.

People sleeping in doorways on George Street. A man shouting at nobody outside the train station, deep in psychological torment. Men and women, many younger than me, carrying the weight of trauma and addiction, sick and alone, in the middle of the day, in the richest city of one of the richest nations on earth.

You do not see this in Canberra – not to the same extent. Not because Canberra has fixed homelessness. It is smaller, wealthier and colder, and its misery is tucked away where the policymaker does not walk. In Sydney, you cannot avoid it. It is at the station entrance, on the Cathedral steps, in the park opposite the office.

Pope Francis had a name for the culture that lets us stride past all this and feel nothing: the globalisation of indifference. So distracted, so insulated, that suffering makes no claim on us at all. And this is not anecdote. Nearly one in five people sleeping rough in inner Sydney is not an Australian resident, and therefore ineligible for social housing, crisis accommodation or homelessness support. Across NSW, the number of people counted sleeping rough has risen 75 per cent since 2020.

Good health starts with a home

Here is a truth so obvious we have managed to forget it. Good health starts with a home. You cannot manage a chronic illness from a park bench. You cannot heal from trauma without safety. You cannot hold down a job, keep appointments or take medication on time when you don't know where you will sleep tonight. A home is not a luxury at the end of the journey to wellbeing. It is the ground the whole thing is built on.

When we fail to provide that ground, people fall through it. Quietly, invisibly, and sometimes fatally.

We now know exactly how fatally. The AIHW has linked homelessness service records to death records. People with a history of homelessness support die at a median age of 55. That is 28 years short of the national life expectancy. Add drug and alcohol treatment and the median age of death falls to 46. More than half these deaths were potentially avoidable. Think about that word. Avoidable. These are deaths from conditions we know how to prevent and know how to treat, in a country with one of the best health systems on earth.

Behind those deaths sits a burden of ordinary, treatable illness. People experiencing homelessness carry chronic disease at rates the rest of the community would not tolerate: heart and lung disease, diabetes, infections, often several at once, and often alongside mental illness. Most of it is exactly what general practice is for. Yet people who have experienced homelessness are around three times as likely as everyone else to face barriers to health care. No Medicare card, no ID, no phone for the appointment reminder, no money for the bus, no safe place to keep medicines. So conditions a GP could manage are left until they become emergencies. These Australians come to emergency departments because there is nowhere else. They are discharged to the street because there is nowhere else. An admission that ends on the footpath is not an episode of care. It is a revolving door, and everyone who works in it knows it.

Why this stays off the agenda

I have spent most of my working life in and around health policy. The people who make health policy are not heartless. Most are the opposite. But two things keep this off the national agenda to the extent it needs to be, and the second matters more than the first. The first is simply distance. The suffering is not always in front of the people who write the briefs.

The second is structural, and it has been tolerated for far too long. Homelessness belongs to state housing departments. Mental health is carved up between Medicare, the states and the NDIS. Drug and alcohol treatment is scattered across federal grants, state programs and charity. Hospitals are funded through a national agreement, split between the states and federal government, that counts admissions, not the reasons the same people keep coming back. Every government can point, accurately, at another government. So the man sleeping at the station entrance is everyone's concern and nobody's responsibility.

The service data tells the story plainly. Specialist homelessness services helped almost 289,000 people last year, and could do nothing at all for 128,915 requests. That figure is a record, up 50 per cent in seven years. The number of clients with a current mental health issue has doubled since 2011 and is now nearly a third of everyone who walks through the door. Among adults sleeping rough it is close to one in two. People with drug and alcohol problems arrive twice as likely to be sleeping rough as other clients, and one in six of them is still on the street when their support ends.

This population does not fit the architecture of Australian health policy, so the architecture ignores them. The people are counted. The deaths are counted. What is missing is not evidence, but ownership.

Where CHA members stand

Catholic health providers never had the option of looking away, and never wanted it. Caring for the people everyone else walks past is not a side project of the Catholic health mission. It is the origin of it. Catholic Social Teaching calls it the preferential option for the poor: the conviction that the first claim on our care belongs to those with the least. The first Catholic hospitals in this country existed for people nobody else would treat.

That tradition is alive, and it is national. St Vincent's has cared for the homeless since the 1850s and opened Australia's first homeless health residential services: The Cottage in Melbourne in 1995, and Tierney House in Sydney, where a person sleeping rough can recover from illness with a bed, meals and a team who know their name. In Melbourne, St Vincent's now runs supported accommodation with housing partners that takes people from years of rough sleeping into care and then into homes, funded by the Victorian Government because it works. Across our network, members run drug and alcohol services, street outreach, mental health beds and hospital-to-home programs for people who have no home to go to. None of this balances on a spreadsheet. It is done because human dignity does not depend on a Medicare card or a lease.

But mission is not a substitute for policy. Providers can catch people as they fall. Only governments can stop the falling.

What should happen

The next round of national health reform should name this population and fund them deliberately. Health and housing planned together, not in separate portfolios. Hospital funding that treats discharge to the street as the failure it is, and pays for the step-down care that prevents it. Mental health and drug and alcohol services a person can actually reach without a fixed address, a GP or a plan. And proper counting, because no health performance framework asks what happens to a patient discharged without a home, and what is not measured is not funded. None of this is beyond us. Australia is not short of money and it is not short of evidence. It is short of attention.

A decent health system is measured by whether it sees the people it is easiest not to see, starting with the man shouting at nobody outside the train station.