Family Practice Vol. 18, No. 3, 272-276
© Oxford University Press 2001
Health Services Research |
Primary health care services for single homeless people: defects and opportunities
Sheffield Institute for Studies on Ageing, University of Sheffield, Community Sciences Centre, Northern General Hospital, Sheffield S5 7AU, UK.
Crane M and Warnes AM. Primary health care services for single homeless people: defects and opportunities. Family Practice 2001; 18: 272–276.
Received 13 June 2000; Revised 3 October 2000; Accepted 8 January 2001.
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Abstract |
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 Top Abstract IntroductionThe Lancefield Street CentreThe implications of primary...ConclusionsReferences |
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Background.An innovative residential centre in west London during 1997–1998 helped older rough sleepers leave the streets and resettle in conventional homes. Many clients presented with multiple physical illnesses complicated by chronicity and poor management. The centre initially experienced difficulties in obtaining health care for the residents, briefly relied on an A&E department for treatment of serious and minor ailments, and latterly was served by a GP practice supported by special funding.
Objective.The aims of this study were to describe the problems of providing at short notice primary health care services to a high-need group, and the prospective opportunities for the delivery of the required care.
Method.A monitoring study collected routine operational data, life histories from 88 residents using a semi-structured questionnaire and information from 61 residents about their contacts with GPs before residence in the centre. Interviews were also conducted with the centre's staff, a Health Authority officer and a GP who treated the residents.
Results.The medical care of the residents was a major concern. Many had physical illnesses yet three-fifths had not seen a GP for more than 5 years. Many were not registered, even among those who recently had become homeless. It was difficult to organize the residents' medical care and to access special funding at short notice. When funding was secured, there were difficulties in contracting the service.
Conclusion.Current registration and commissioning procedures are ill fitted to provide primary care services to a high-needs group at short notice. Primary Care Groups, special funding and contractual arrangements provide opportunities for GPs and primary health care workers to provide an improved service to marginalized and special needs groups. The responsibility to identify and respond to exceptional needs should be clearly defined and allocated.
Keywords. High needs, homeless, Primary Care Act Pilot Sites, Primary Care Groups, primary health care.
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Introduction |
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TopAbstractIntroductionThe Lancefield Street CentreThe implications of primary...ConclusionsReferences |
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The NHS is committed to providing a dependable health service for all, yet marginal groups, such as alcoholics, drug addicts, traveller gypsies, the mentally ill and single homeless people, have generally been poorly served and are sometimes ‘excluded’. Although single homelessness is associated with high rates of physical illnesses,1 many homeless people are not registered with GPs and do not receive medical care. Access to and the delivery of health care are functions of the organization of the services, the skills of health workers, their attitudes towards marginal and ‘problematic’ patients, and homeless people's behaviour. This paper examines the difficulties in providing primary health care to single homeless people, and the prospective opportunities for improvement.
The paper draws on the experience of the Lancefield Street Centre in west London, which operated for 24 months from January 1997 and targeted older people sleeping rough, i.e. on the streets. It was managed by St Mungo's, a voluntary housing association which specializes in services for single homeless people. The centre provided street out-reach work, a 24-hour drop-in centre, a 33-bed hostel and a resettlement programme.2 The health problems of the residents and successive arrangements for the provision of primary health care services are described. This is followed by an examination of the implications for homeless people of the revisions to primary health care provision.
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The Lancefield Street Centre |
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TopAbstractIntroductionThe Lancefield Street CentreThe implications of primary...ConclusionsReferences |
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Data sources
Information on the physical and mental health problems of the residents and the provision of health care was gathered over 24 months at the Lancefield Street Centre.3 Three routine operational databases were created covering the out-reach workers' contacts, the users of the drop-in centre and the hostel residents. Life histories were collected from 88 residents using a semi-structured questionnaire; a survey of 61 residents collected data on contacts with GPs before admission to Lancefield Street; and interviews were conducted with the centre's staff, a Health Authority officer and a GP who treated the residents.
The hostel residents
From January 1997 to December 1998, 157 men and 14 women aged 50 years and over were admitted to the hostel, 49% being aged at least 60 years. Fifty-seven percent had been homeless for >5 years, including 42% for >10 years. On admission, 55% had physical health problems, with cases of tuberculosis, jaundice and ascites from liver and renal failure, carcinomas, severe anaemia and fractured limbs. Less critical problems included diabetes, arthritis and bronchitis. Some with severe problems had not sought treatment. Two men collapsed a few hours after admission, were taken to hospital and died soon after. Almost two-fifths (39%) had mental health problems, 12% marked memory problems, and 58% were heavy drinkers. The heavy drinkers were more likely than others to have physical illnesses (chi-square = 12.6, d.f. = 1, P < 0.0005) (Table 1
).
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Two-fifths of the residents required assistance with personal hygiene and bathing, and 15% were incontinent frequently. Many needed supervision with meals and health care, and had to be reminded to take medication, encouraged to have dressings replaced, and doctors' appointments had to be arranged for them. Fifty residents (29%) were admitted to hospitals on 107 occasions between March 1997 and the closure in December 1998, during which period five died. Six former residents also died during this period. For comparison, only 10% of the general population in England and Wales aged 60–74 years and 18% of those aged 75 years or more were admitted to hospital in the year 1994– 1995.4 The principal reasons for admission were epileptic seizures, kidney and liver failure, ruptured oesophageal varices, pneumonia, tuberculosis, asthmatic attacks and injuries from falls. Most of those admitted for seizures, kidney and liver failure, and injuries had been heavy drinkers for years. A profile of the residents' personal care and health problems demonstrates their high needs (Table 2
).
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Use of medical services prior to admission to Lancefield Street
Of 61 residents on admission, 59% said that they were registered with a GP (only 54% with a London practitioner). Only 32% had seen a GP within 6 months, and 59% had had no contact with a doctor for >5 years (for some, >20 years). In contrast, 98% of the UK population is registered,5 and 65% of men and 75% of women consult their GP in 1 year.6 The presence or absence of alcohol problems was not associated with GP contact frequency, but mental health problems were significantly related. Of those with a mental illness or marked memory problems, 78% had not seen a GP for 5 years, compared with 42% without those problems (chi-square = 7.1, d.f. = 1, P < 0.01).
The majority of the unregistered residents had not sought registration recently. Some had low self-esteem and attached low priority to their health. Others did not recognize the severity of their illnesses, or feared doctors and their appointment systems and procedures. Most had no contact with family or friends who might have encouraged them to seek medical care. It was expected that the newly homeless group would have had more contact with GPs, but 13 of the 16 people who had become homeless in the 12 months prior to admission were either unregistered (eight cases) or had not consulted their doctor in 5 years (five cases).
The provision of health care at Lancefield Street
The hostel initially experienced difficulties in organizing health care for the residents. While most local GPs were reluctant to register the residents, one accepted them as temporary patients, saw them at her surgery and conducted a weekly clinic at the hostel. The clinic ceased after 2 months, and 6 months later the GP gave notice that she was unable to provide any service. Most residents were without a GP from September 1997, when the first point of contact for medical care was the A&E department of St Mary's Hospital. The hostel staff became responsible for recognizing physical illnesses, deciding when medical care should be sought and ensuring that the clients complied with treatments. Kensington, Chelsea and Westminster Health Authority planned to appoint a nurse practitioner for the centre, but when funding was secured it proved impossible to recruit. In December 1997, the Health Authority funded a local practice to treat the residents, an arrangement that continued until closure. A drop-in clinic at the surgery was arranged four afternoons each week, at which the residents (and other patients) were seen without appointments.
The single responsible practice had several benefits for the hostel residents and the staff. Good links were developed with the GPs, and there was 24 hour cover. The residents came both to know the GPs and to be more willing to attend appointments and accept treatment. The drop-in clinic was particularly valuable, for its unarranged appointments suited the residents who initially refused but later were persuaded to attend. The flexible hours meant that hostel staff could escort some residents to the clinic, describe symptoms to the GP and note future appointments and prescribed medication.
According to one of the GPs, the hostel residents were registered as temporary patients, but many required intensive medical care. ‘Normal’ temporary patients seldom require extensive investigations, continuous treatment or repeated home visits. The residents' multiple problems were complicated through chronicity and poor management. Treating the illnesses was problematic because most residents were unable to provide a medical history and had little insight into their health problems. The GP was therefore unaware of past illnesses, investigations and treatments. Many residents required extensive hospital investigations but, because some only stayed briefly, it was difficult to arrange out-patient appointments and the continuity of care. The work was more crisis management than the control of illnesses: it was sometimes difficult to know if there were underlying and undetected problems, and probably some investigations were repeated wastefully. The work was found to be challenging and rewarding, and the practice would have been willing to continue to treat the residents if the hostel had not closed, provided that the excess workload was recognized and funded.
The arrangement undoubtedly conserved NHS resources. When there was no GP cover, the use of A&E for serious and minor ailments was a costly way to provide primary care. A 1992 survey estimated that the medical problems of 57% of the 3525 visits by homeless people to A&E at London's University College Hospital could have been managed by general practice services.7 The cost of an ‘inappropriate’ visit to the A&E department was estimated as £44, compared with £15.49 for a GP consultation. Hostel dwellers with access to a GP rarely used A&E inappropriately.7
There was little time before the Lancefield Street Centre opened for its managers and the Health Authority to plan collaboratively the general practice service. Voluntary organizations in the homeless sector have to set up projects opportunistically when grants or buildings become available. St Mungo's spent 4 years searching for accommodation for the project. The building had just a 2-year lease, and a rapid opening was necessary. Moreover, only once in operation did the severe health problems and high care needs of many residents became apparent, placing the difficult problem upon the Health Authority of finding unbudgeted funds and GPs willing to provide a service.
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The implications of primary health care reforms for single homeless people |
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TopAbstractIntroductionThe Lancefield Street CentreThe implications of primary...ConclusionsReferences |
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The experience of the Lancefield Street Centre demonstrated that the arrangements for GP registration and primary care commissioning were unable to respond quickly to the health care requirements of highneed patients, particularly when a local concentration formed with no notice. Since the launch in 1997 of the NHS (Primary Care) Act, the White Paper, The New NHS: Modern, Dependable, and the inauguration in April 1999 of Primary Care Groups (PCGs), new opportunities are opening up for marginalized and special needs groups to receive improved primary health care services. Primary Care Act Pilot Sites (PCAPS) are trialing flexible contractual arrangements by which GPs and allied staff deliver personal medical services to underserved groups, such as the elderly, mentally ill or homeless people, or to those in deprived or low income areas.8
In April 1998, GMS Local Development Schemes (LDS) were also introduced. Health authorities are able to improve the development and responsiveness of general medical services, through additional payments for work in deprived areas with high morbidity populations and workloads. Homeless people are stipulated as a group that will benefit. Additional funds would enable GPs to register homeless people, visit them in hostels, see them at the surgery without appointments, conduct comprehensive mental and physical assessments, and arrange investigations and treatment programmes. The funding would also support practice nurses, community psychiatric nurses and alcohol counsellors involved in their care.9
The extent to which the current reforms in primary health care provision will address the needs of marginalized groups is however unclear. Under current arrangements, health authorities have a responsibility to ensure that local health needs are met and to organize services when unmet need is identified. They are responsible for including LDS plans in their services and financial framework, and for ‘ring-fencing’ money from the national GP renumeration pool for purchasing PCAPS in a local contractual framework. With the creation of PCGs and later Trusts, the commissioning role of health authorities will be diluted. Neither the future location nor the force of the public health responsibility as between PCG/Ts and health authorities is yet clear; nor therefore their capability to allocate funds and organize services in response to concentrations of special needs.
The involvement of GPs in PCGs and in purchasing decisions may reduce rather than increase their services to high-needs groups. The pressure on the new primary care organizations is to tackle geographical (or ‘postcode’) variations in the availability of primary health care, and to minimize the underserved fraction of the ‘general’ population, not to provide intensive health care for high-needs groups alongside a ‘normal’ caseload. Many GPs find homeless people difficult to help, with their transient lifestyle, high treatment needs and poor compliance.10 Their exceptional demands add to a high workload and compromise the care that can be delivered to the majority of housed patients, perhaps particularly for single-handed practitioners (which in London in 1997 formed 46% of practices).11 Furthermore, the targets that GPs are required to meet tend to focus on readily measured indicators such as the uptake of health screening, and fail to reflect the variation in needs and willingness to accept services among different practice populations.12
The extent to which PCAPS and LDS will work with the most marginalized and difficult groups, or concentrate on those who are vulnerable but have less severe needs and are easier to help, is unknown. There are difficulties in recruiting health care staff to work with marginalized groups. Among 81 GPs in a London survey, two-thirds said that a capitation fee would not increase their willingness to work with alcohol misusers, and three-quarters that it would not make them more willing to work with drug users.13 When funds were available for specialist primary health care services for homeless people, there were difficulties in recruiting staff.14 The contracting and salary arrangements of PCAPS and LDS may not be sufficient to overcome this widespread disinclination to serve problematic client groups. It is possible that single homeless people will be neglected by both PCGs and PCAPS.
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Conclusions |
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TopAbstractIntroductionThe Lancefield Street CentreThe implications of primary...ConclusionsReferences |
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The current primary care reforms aim to create new opportunities for appropriate health care to be delivered to underserved and marginalized populations, but for the latter at least the changes may have the opposite effect. The intensive and flexible arrangements provided through PCAPS and LDS are likely to provide improved services to underserved areas and populations but will not automatically do so for patients with high needs and those who do not present. The duty to identify and fund services for such populations should be clearly specified and placed with agencies superordinate to Primary Care Trusts, and those agencies should commission services which seek out unregistered patients and meet their unmet health care needs. The recruitment of GPs and other health care staff to work with marginalized client groups should be encouraged through incentives, training and realistic target setting, and ways of providing effective primary health care to homeless people should be trialed through PCAPS and LDS pilots.
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Acknowledgments |
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We thank the managers of St Mungo's, the residents and staff at Lancefield Street and Dr M Sarnicki for their co-operation and time, and the King's Fund, the Henry Smith's Charity and the School of Health and Related Research, University of Sheffield, which funded this research.
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References |
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TopAbstractIntroductionThe Lancefield Street CentreThe implications of primary...ConclusionsReferences |
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2
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