The homeless community: breaking down the barriers to primary care

The number of homeless adults on our streets is increasing which, due to their associated health problems, is causing increasing demand and inefficiencies on the National Health Service (NHS).

Currently the homeless are experiencing inequalities of healthcare due to a lack of access to primary care. As a consequence, there has been an increasing use of secondary care, which has become the preferred provider of healthcare for the homeless community. Homeless health is often complex involving tri morbidity and although legislation already exists to embrace these needs within current models of primary care, they are not being met. Innovative and specific healthcare models are needed in order to access this disengaged community. This project is focussed on delivering an accessible primary care clinic specifically for the homeless community. The project will deliver improved efficiencies and reduced costs for the NHS, including ambulance services, which will benefit the wider community and reduce the inequalities of health currently being experienced. It is hypothesised that this increased provision of primary care to the homeless demographic will result in reduced morbidity and mortality, improved health and a more efficient NHS which is vital in the current climate of austerity and uncertainty.

Homeless health

Being homeless and sleeping rough is sadly not a new phenomenon. The numbers of homeless people all across England have been increasing over recent years (Crisis, 2016; DCLG, 2016) and a research project carried out on behalf of ‘Crisis’ and the ‘Joseph Rowntree Foundation’ suggests that the numbers will continue to rise in the future (Crisis, 2017) In England, the estimated number of rough sleepers in 2010 was 1768 (Crisis, 2016), 3569 in 2015 and 4134 in autumn 2016 (DCLG, 2016). In Manchester the figure was estimated to be 7 in 2010 and 70 in 2015 (Crisis, 2016). In 2015 there had been a 62% increase in rough sleepers in Manchester from the previous year. This is much higher than the national average increase of 30%, which makes Manchester the fourth highest area of rough sleepers in the UK (DCLG, 2016; UVMP, 2016). The rapid increase in the numbers of homeless adults in Manchester has been attributed to the thriving night life and its associated opportunities to access street funds (UVMP, 2016). The Voluntary groups who often work closely with the homeless community believe that the figures produced by local government largely underestimate the true numbers of homeless in their areas (Crisis, 2017). The average age of death for the homeless is 47 years for men and 43 years for women (UVMP, 2016. DoH, 2010). Homelessness itself is a marker of morbidity and many of the homeless have a long-term mental, physical or addiction problem (Aspinall, 2014; Fazel et al, 2014). These health problems are then often left unattended due to the homeless community experiencing barriers to accessing primary care (Riley et al, 2003; Canavan et al, 2012; Aspinall, 2014).

Defining ‘homeless’

During this review of service provision, the definition of homeless will be that used by the Department of Health (DoH) (2010) and include: No fixed abode (NFA) / rough sleepers. Those residing in a squat or hostel and those people who are ‘sofa surfing’ or leading a transient lifestyle These groups are deemed high risk for being interchangeable, meaning that all three groups can often spend time rough sleeping on the streets. The definition does not include those in temporary accommodation provided by a local authority under homelessness legislation or those living in unsuitable or overcrowded accommodation. Although these groups may be defined as vulnerable the DoH does not deem them to have significantly different health needs than the general homed population (DoH, 2014).

Barriers to primary care

There are many reasons why the homeless do not already access primary care. An often stated barrier to primary care for the homeless community is the prerequisite of having an address to fulfil the registration process (Aspinall, 2014). Although registration with GPs seems to be going up, so are the numbers of homeless (DCLG, 2016. Crisis, 2016) and therefore the use of secondary care (DoH, 2010; Homeless link, 2014; Story et al, 2014). Not having a home address should never have been a barrier to registration, a fact clearly stated in the primary care registration document (NHS England, 2015). The original recommendation to ensure all patients wishing to register had an address was in an effort to reduce ‘health tourism’ and was in fact offered as a suggestion for good practice in Manchester, not a legal requirement (charter for homeless health, 2016). Homeless link (2016) also found that barriers to registering with a GP and actually making and keeping appointments are often related to their chaotic lifestyles which are commonly worsened by some type of substance misuse (Canavan et al, 2012; Homeless link, 2016). Other barriers are the transient and often unpredictable nature of the homeless (Aspinall, 2014). Drug users feel discouraged from seeing doctors due to feeling that they may be treated as criminals (BMA 2014). As substance misuse is part of the tri-morbidity strongly associated with homelessness this can be identified as another reason for lack of engagement with traditional primary care. Homeless health needs survey conducted by UVMP in 2016 identified that 64% of local homeless people report having a diagnosis of depression, 73% report a mental health issue and 57% report anxiety. Clearly unmanaged mental health problems will reduce ability to function and therefore engage with issues of physical health (St Mungos, 2014). Engaging with the targeted clinic at a place already habitually attended will allow an access point for services to manage these conditions and allow better onward management of physical health.

Language barriers are another real problem for some homeless migrants and failed asylum seekers when attempting to register with a GP (Biswas et al, 2011; Newbold et al, 2013). 17% of rough sleepers are EU nationals from outside EU and 5% are from outside EU (DCLG, 2016). The lifestyle characteristics of the homeless often making it difficult to keep appointments, instead allowing illness to escalate until attending the ED is favourable (which is available without appointment and 24hrs a day 365 days a year). It is well documented that Homeless are more likely to seek medical help from the emergency department (ED) rather than a GP (DoH, 2010; Crisis, 2011; Story et al, 2014). It is hoped this can be changed in favour of the clinic which can then communicate the benefits of access primary care.

Emergency Department provision for primary care problems

Whether the complex exacerbations of chronic health problems within the homeless community could be managed successfully by primary care is unclear. However, it is clear that primary care can do more leading up to the acute exacerbations, which was highlighted by the royal college of general practitioners in a statement on homeless health and primary care (RCGP, 2002), where they suggested homeless health be managed as part of core primary care organisation. There is further data to support early intervention in homeless health matters (St Mungos, 2014) which is supported by the secretary of state who informed NHS England to make further progress in transforming primary care with a focus on those patients who have the most complex needs (Parliament UK, 2014). Evidence is available to show that appropriate delivery and engagement of primary care services could significantly increase the use of primary care services by the homeless community (Aspinall, 2014). The financial motivator to focus on primary care is supported by clear evidence showing the cost of accessing primary care is significantly less than secondary care (New Economy, 2015). This supports the hypothesis that a targeted primary care service will be a success for both the patients in terms of health and the stakeholders in terms of financial efficiencies.

The cost of inaction

In Manchester, 42% of homeless admitted using an ambulance in 2015–16 and 57% admitted attending emergency departments (Manchester homeless health needs audit, 2016). The average cost of an ambulance is £216. Cost of ED attendance is £132 and the average cost of non-elective hospital admission is £1565 (Homeless health needs, 2016). On average homeless people are likely to attend ED six times as often as the general public. From those attendances they are four times as likely to be admitted and once this happens they stay three times as long as they have allowed sickness to develop to a greater extent. This results in acute services being four times as expensive and unscheduled hospital costs eight times as expensive as the general public (DoH, 2010). DoH estimate homeless use of healthcare to cost a minimum of £85 million a year (homeless link, 2014). This project will aim to reduce the local burden by engaging with the homeless community and introducing them to primary care and reducing these ambulance and hospital costs. Within the locality of PAT, there are three emergency departments (ED) and one urgent care centre (UCC). The combined attendances for north Manchester general hospital (NMGH), Fairfield general hospital (FGH) and Rochdale infirmary Urgent care centre (RIUCC) during 2014-16 are 1454 (PAT, 2016). This gives a substantial target group for the project to engage with and introduce to primary care.

The solution

This innovative project aims to balance the current inequality of healthcare and deliver the right service at the right time to the local homeless community of North Manchester It is hoped that increased engagement with primary care will then improve general health, quality of life and reduce deterioration of long term manageable conditions. A sad fact is, the homeless invariably die of relatively simple medical conditions and not of exposure as is often assumed (Cabinet Office, 2010; Metcalf et al, 2014).

The original hypothesised solution to the issue of inequality of health for the homeless community was to develop a mobile clinic in conjunction with the local ambulance service and the NHS Trusts' community team. Due to a number of reasons including staffing levels and funding, this solution while deemed innovative and received with positive response, lost favour at the point of implementation. There was deemed a need to prove that the hypothesis of a specific clinic could engage with the homeless community to reduce mortality and morbidity as well as reducing the use of ED. The initial temporary solution has now been thought to actually be a more suitable long term solution and can be reproducible with minimum effort across all areas of the UK. A specific homeless clinic will be established in a local day centre for the homeless which already has a varied number of targeted services for this demographic. The CCG will fund a local GP practice to supply a GP to a regular once weekly session. The CCG have expressed interest due to the huge cost saving implications and presumably the moral and ethical need. Patient will be registered through EMIS linked to the practice; this will be done prior to treatments beginning. This full registration via EMIS allows the complete range of services to be accessed along with safe governance. If no address is available to the patients, they can register to the day centre which will manage the administration of patient letters.

The clinic will be a walk in service in order to cater for the chaotic lifestyles of the homeless (St Mungos, 2014). The times for the clinics will be agreed through discussion with the local patient target group. Engaging with communities for the development of their healthcare has been widely accepted (WHO, 2008;2010; Canada, 2010; Neuwelt, 2012) and indeed is considered to be a core attribute for new healthcare policy (WHO, 2015). With this in mind, a questionnaire was developed and distributed at the homeless day centre where the clinic will operate.

Leadership

The process of identifying and engaging with key stakeholders and developing the hypothesis has been a leadership challenge. “Leadership is the eighth wonder of the world” according to Burnison (2012) and he suggested that, it is easier to see and feel leadership than to actually define leadership. It is this point that I hope will encourage other paramedics to take up the challenge and make a change even if they feel unsure or out of their depth. The way to learn is to do. Nel, Werner, Haasbroek, Poisat, Sono, and Schultz (2008) define leadership as the ability of an individual to coax the behaviour of others into achieving a desired result, goal or objective.

My personal alignment to transformational and authentic leadership styles is generally good but it has been good to look at these styles to more formally assess myself in a leadership role. I have realised that there is a recognised type of leader for the particular area I work in which considers the personality types of the people I work with. Although I cannot change myself to perfectly fit the required leader profile, I can, with this new knowledge, address areas of weakness and enhance current strengths. As will all aspects of myself and my knowledge, much work is still required.

What can we provide?

Early intervention by primary care for these at risk groups can manage these minor illnesses and avoid exacerbation of more chronic illness which may even be undiagnosed. As an example, chronic obstructive pulmonary disease (COPD) has a prevalence of three million in the UK with estimated two million undiagnosed (NICE CKS, 2010). COPD is associated with smoking and 87% of homeless report to be smokers (Homeless health needs audit, 2016). It is also associated with deprivation and co morbidities (Decramer, M. Janssens, W, 2013). Referrals for COPD may be appropriate at any stage of the disease (NICE, 2010) so the engagement of homeless with primary care through the clinic will clearly improve management of this particular disease for this specific high risk demographic. It is widely hypothesised that these early interventions by primary care will be overall cost saving initiatives for NHS however it is also acknowledged that there has not been enough research to prove this (St Mungos, 2013). The clinic team will collate data to add to the evidences available in order to improve health in the long term and further support homeless health initiatives. It is thought likely that DVT pathway will be the most commonly used so this will be streamlined as a priority. It is likely that Doppler clinic will form part of the walk in service and be held at the day centre.

Supporting policy

Homelessness is on the agenda of local government and Manchester health and wellbeing board run by Manchester city council and the Manchester homeless charter aims to eradicate homelessness in Manchester through partnerships with healthcare, council, faith groups, businesses and charities and adoption of their core principles (street support network, 2016). None of these however aim at providing medical care, so a gap was identified that the homeless clinic will fill. Health services for the homeless are however on the national healthcare radar, with combined department commissioning being delivered through department of health and NHS England who are working closely with the faculty of homelessness and inclusion health and the national inclusion health board (Faculty of Homeless and inclusion health, 2014). National guidance can be found to support the ethos of the project as NHS England is obliged to provide primary care services to ALL patients in England (Health and Social care act, 2012). The Health and Social Care act (2012) also specifically states that one of the duties of NHS England is to “have regard to the need to reduce inequalities” regarding access to primary care. There are other relevant acts specifically imposed on NHS England regarding inequalities of health (DoH, 2010a) (NHS act, 2006). Another national reminder of policy is from the Clinical Quality Commission (CQC) who has developed guidance called: “Mythbuster 29: looking after homeless patients in general practice”. The lack of access and engagement with primary care for the homeless community is a significant factor that leads to early and preventable death from medical conditions rather than exposure as is often perceived (Metcalf, P. Russell, K, G, 2014. Cabinet Office, 2010). The project initiative will endeavour to link in with best practices shown through the UVMP and MPATH projects while engaging with local community and GP practices to break down barriers and educate all parties in the current and emerging government policies. It is believed that the projects aim in facilitating full registration for the homeless with a local engaging GP will help to balance the current inequality of health care provision, reduce mortality and save costs for the NHS in the current climate of austerity To support the wider homeless community in their attempts to gain registration with other primary care practices, a leaflet has been produced to inform both patient and practice of the individuals rights and supporting government policy.

Summary

The well documented fact that homeless numbers are increasing (Crisis, 2016; DCLG, 2016) means a project such as this is not only needed but will become more relevant and efficient financially as the homeless numbers increase. The project proposes audits at 3,6 and 12 month periods in order to facilitate evidence based service developments. It is hoped that the audit will also provide supporting evidence for the projects effectiveness in reducing ED attendances and increasing GP registration. Audits of the service would be ongoing from that point, as required by Health Act (2009), in order to continue offering a much needed and accessible service as efficiently and targeted as possible. Ethics considerations and confidentiality will be paramount for any part of auditing involving direct patient questioning or identification as specified by NHS Health Research Authority (2016).

Conclusion

It is hoped that this work clearly highlights and expressed the need for targeted primary care services to the homeless and that the solution developed can be recreated anywhere in the UK. The author would encourage all paramedics to consider a similar project in order to reduce mortality and morbidity in this demographic and also to reduce workload to your ambulance services and colleagues in ED.

Key Points

  • Percussion pacing might be a feasible and lifesaving measure in extreme bradycardia and p-wave asystole.
  • A clenched fist rhythmically tapping the patients lower left sternum might result in electrical capture and ventricular contraction.
  • Percussion pacing is not scientifically supported but described to be successful in several case series and case reports.