Dr Dana Beale suspects the woman sitting in front of her has bowel cancer. She’s already complained of pain and bleeding when she goes to the toilet and Beale, a GP, has referred her for a hospital appointment. The woman is glad but also hesitant and asks whether she might have to pay for the appointment. Beale says yes.

The woman starts to cry. She is Roma and is in the UK alone, living rough on the streets of Westminster after she was lured here by a man promising work. She is destitute and doesn’t speak English; Beale is communicating with her using a telephone interpreting service. Beale worries the woman is at risk of being exploited as a slave, like some of her other patients.

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“How can home be so bad that this is better?” Beale asks. “As doctors, we want her to get the care she needs but it’s so difficult in the current hostile environment, which is growing more hostile every month. Hospitals are going overboard.” She tells of one rough sleeper who is missing, presumed dead, after he was diagnosed with cancer and told it was operable, but that he would have to pay to get his tumour removed. Another patient, who had a stroke which left them unable to move and talk and who is unlikely to make even a partial recovery, is to be charged for treatment, the cost of which will likely be hundreds of thousands of pounds.

Beale is one of a team of healthcare professionals working in Great Chapel Street Medical Centre, a specialist homeless GP practice in central London. She works in tandem with another GP, Dr Natalie Miller; also on the medical team are a dentist, a counsellor, a legal adviser, a psychiatrist, a podiatrist, a nurse and a mental health social worker.

Facebook Twitter Pinterest ‘We see people when they’re at the lowest point and have lost everything.’ Photograph: Alicia Canter/The Guardian

The service is funded by the NHS central London clinical commissioning group to try to reduce the number of homeless people attending A&E and being admitted to hospital. Around 700 patients are registered at the practice, about a third of whom are thought to have no right to NHS hospital care. These people are typically refused asylum seekers, those who have overstayed their visa, or European economic area nationals who are deemed to have not worked enough to fulfil their treaty rights.

According to Beale and Miller, a few years ago this didn’t present much of a problem. In October 2017, however, new regulations were introduced as part of the government’s hostile environment policy. Since then, both have seen cases of patients with conditions including cancer, hepatitis, and mental health problems such as post-traumatic stress disorder, or requiring end-of-life care, being denied treatment or told to pay thousands of pounds upfront.

Patients may be scared to attend hospital as a result and when they can’t afford the treatment, they go without care and their conditions worsen, say Beale and Miller. Treatment deemed urgent or “immediately necessary” is meant to still be carried out regardless of ability to pay.

“From our point of view, we see people when they’re at the lowest point and have lost everything,” says Beale. “It’s so cruel and the rules aren’t being applied correctly and are poorly implemented. People are almost too scared to set foot in hospital.” She cites one example of a patient visiting A&E when he had an asthma attack and being asked to show his passport.

Homeless health is a serious and pressing issue for those who are eligible for NHS care, let alone those who aren’t. Homeless deaths in England and Wales have risen every year since 2014, increasing from 482 to 597 in 2017, according to government figures. The average age of a rough sleeper at death was 44 among men and 42 for women. The largest numbers of deaths of homeless people were in London and the north-west of England.

The impact of the hostile environment that has encroached on the NHS is making things worse, according to Beale and Miller. “There are many thousands more hidden homeless that we don’t see,” says Beale. “The problem is likely to explode and we predict seeing many more deaths due to this hostile environment.”

Back in the consultation room, a woman from the Czech Republic sits with Miller. She has come in to get the results of some routine blood tests. Halfway through hearing them, she breaks down in tears and tells Miller her legs are swollen and red. After examination, Miller suspects she has cellulitis, a bacterial skin infection, which – if not treated with antibiotics – can be fatal. Miller tells her to sit in the waiting room. She says afterwards: “She desperately needs a bed. If she deteriorates she might need to go to hospital within hours or days. I don’t know what the other options are.”

It’s 3pm in the afternoon and the race is on to try to find an available bed for the night. There’s a queue of patients waiting to be seen so the practice manager and legal adviser step in to help. At 5pm, after countless phone calls, they haven’t found anywhere for her to sleep and so the woman is left to spend the night on the streets.

Everyone is worried but the team has exhausted every available option. Miles Davis, the practice manager, says: “You try not to think about people dying. We do as much as we can and set as much up as we can and hope that works.”