How To Improve Your Service (and create headroom and reduce stress)
As stated from the outset, the aim of this resource is to provide information that might help improve the quality of and access to primary healthcare for homeless groups. Remember there is an argument to support a political, moral and legal duty to do so (REF). We also recognise the very real pressure primary care services are under.
So how can things be improved without losing more time and without simply creating added workload?
Why Bother?
Firstly there are the legal, moral, and political reasons previously mentioned. Secondly, there is evidence that investing into and improving primary care services for homeless patients can save money, especially in terms of avoided hospital admissions/attendances and reduced length of stay if an inpatient (LONDON PATHWAY). The chief analyst at the Department of Health has also estimated that the health spend on each homeless person is 4x the amount spent on those with a fixed abode. After that, evidence of the economic benefit to improving access in mainstream primary care is more conspicuous by it's absence than it's results. Nevertheless, the economic argument could be just one amidst many others that justify improving things for homeless groups.
The Benefits of a 'Specialist Model'
There are many centres, almost exclusively in larger urban centres, that provide primary health care services to homeless patients. Often these are services specifically set up to provide care exclusively to homeless patients and are funded in various ways (bespoke PMS contracts or via hospital/mental health trusts). These might be called 'specialist' centres and some examples include:
Whilst they provide a much needed service, one possible 'flaw' is that they are totally separate from mainstream primary care an thus are not fully integrative with the rest of society. This could have negative consequences if a homeless patient leaves the area served by a specialist primary care service and becomes housed because the primary care system they will then have to register with might be very different to what they have been used to.
The Trouble With the 'Mainstream' Primary Care Model
As eluded to above, homeless primary care services typical operate a drop in basis and have very close working relationships with housing, alcohol, drug and mental health teams. Appointments are often long because the problems presented are usually very complex. Staff are often specially trained to deal with the issues that are common. This will seem obviously different to the more conventional or 'mainstream' primary care model most surgeries adopt. The barriers to providing the same level of care that exist in mainstream primary care might include how:
You can divide these barriers into ORGANISATIONAL issues and SKILLS/ATTITUDES. Both sets of issues can theoretically be addressed and overcome. We will now explore this further with the idea of a hybrid model and then go on explain how such a model can fit into mainstream primary care.
A 'Hybrid Model' for Homeless Health Care
So we have two conflicting needs: one is a need to improve access for homeless groups outside of major urban centres (who already have 'specialist' services) and a need to do so without fundamentally changing a model that is perhaps not best suited to achieving that. It seems like an impasse but we suggest it needn't be.
What if a mainstream primary care surgery could offer additional and more flexible services to it's homeless populations without jeopardising the general work it is contracted to provide? In reality this already happens in every surgery via enhanced service contracts. Health checks, immunisation schedules and screening programs all need something other than '10 minutes with a GP' and so are afforded funding to allow them to occur as well as (and not instead of) general medical services.
There are actually already surgeries who operate a hybrid model of health care to homeless people that have additional funding to provide an extra level of service (essentially an enhanced services contract) specifically for homeless groups. Some examples of such surgeries include:
The Bassett Road Surgery - Leighton Buzzard
Leighton Buzzard is a market town with a small but significant homeless population. There are 4 surgeries in the locality and one has an enhanced services contract which allows them to provide outreach appointments at the local homeless shelter, which is geographically close to the surgery.
The practice has close links with the shelter and the charity that runs it. In practice, the patient pathway is often as follows:
Record Keeping & Data Collection
Records are kept of how many people are seen at outreach each week and a 'homeless register' of patients is kept for audit purposes. It is therefore possible to track how many patient contacts there have been and also who might be in need of targeted support (such as a care plan). For example, it might be possible to see that a small number of homeless patients are accounting for a large proportion of unplanned A&E attendances. It might then be possible, through liaison with the shelter, to explore the issues further and perhaps put in any extra support or appointments to change that trend.
So, in summary, The Bassett Road Surgery:
The exact way each of the three surgeries operate in their local area as unique as the surgeries themselves but all have gone through a process of identifying and acting on a recognised need through collaboration with their local existing homeless services and their respective commissioners.
We will now move from examples to a suggestion of how you might go about making the case for an enhanced service for your practice, if the need was there.
So how can things be improved without losing more time and without simply creating added workload?
Why Bother?
Firstly there are the legal, moral, and political reasons previously mentioned. Secondly, there is evidence that investing into and improving primary care services for homeless patients can save money, especially in terms of avoided hospital admissions/attendances and reduced length of stay if an inpatient (LONDON PATHWAY). The chief analyst at the Department of Health has also estimated that the health spend on each homeless person is 4x the amount spent on those with a fixed abode. After that, evidence of the economic benefit to improving access in mainstream primary care is more conspicuous by it's absence than it's results. Nevertheless, the economic argument could be just one amidst many others that justify improving things for homeless groups.
The Benefits of a 'Specialist Model'
There are many centres, almost exclusively in larger urban centres, that provide primary health care services to homeless patients. Often these are services specifically set up to provide care exclusively to homeless patients and are funded in various ways (bespoke PMS contracts or via hospital/mental health trusts). These might be called 'specialist' centres and some examples include:
- The Luther Street Medical Centre - Oxford
- E1 Health Centre - Tower Hamlets
- The Homeless Primary Care Team - Birmingham
- York Street Health Service - Leeds
- Brighton Homeless Healthcare - Brighton
Whilst they provide a much needed service, one possible 'flaw' is that they are totally separate from mainstream primary care an thus are not fully integrative with the rest of society. This could have negative consequences if a homeless patient leaves the area served by a specialist primary care service and becomes housed because the primary care system they will then have to register with might be very different to what they have been used to.
The Trouble With the 'Mainstream' Primary Care Model
As eluded to above, homeless primary care services typical operate a drop in basis and have very close working relationships with housing, alcohol, drug and mental health teams. Appointments are often long because the problems presented are usually very complex. Staff are often specially trained to deal with the issues that are common. This will seem obviously different to the more conventional or 'mainstream' primary care model most surgeries adopt. The barriers to providing the same level of care that exist in mainstream primary care might include how:
- 10 minute appointments may not be long enough.
- Chaotic and 'immediate need' lifestyles of many homeless patients do not fit well with a book in advance appointment system
- Registration regulations might be prohibitory to homeless patients.
- Seeing a homeless patient only to refer them somewhere else for treatment (such as a drug worker) may only add further barriers to them accessing the care they would most benefit from.
- Some primary care staff may be insufficiently trained to deal with complex mental health needs, housing issues and drug/alcohol misuse.
- Some primary care staff and other patients may have negative feelings towards homeless groups due to stereotyping and the existing stigma of homelessness
You can divide these barriers into ORGANISATIONAL issues and SKILLS/ATTITUDES. Both sets of issues can theoretically be addressed and overcome. We will now explore this further with the idea of a hybrid model and then go on explain how such a model can fit into mainstream primary care.
A 'Hybrid Model' for Homeless Health Care
So we have two conflicting needs: one is a need to improve access for homeless groups outside of major urban centres (who already have 'specialist' services) and a need to do so without fundamentally changing a model that is perhaps not best suited to achieving that. It seems like an impasse but we suggest it needn't be.
What if a mainstream primary care surgery could offer additional and more flexible services to it's homeless populations without jeopardising the general work it is contracted to provide? In reality this already happens in every surgery via enhanced service contracts. Health checks, immunisation schedules and screening programs all need something other than '10 minutes with a GP' and so are afforded funding to allow them to occur as well as (and not instead of) general medical services.
There are actually already surgeries who operate a hybrid model of health care to homeless people that have additional funding to provide an extra level of service (essentially an enhanced services contract) specifically for homeless groups. Some examples of such surgeries include:
- The Cambridge Access Surgery - Cambridge
- St Clement's Partnership - Winchester
- The Bassett Road Surgery - Leighton Buzzard
The Bassett Road Surgery - Leighton Buzzard
Leighton Buzzard is a market town with a small but significant homeless population. There are 4 surgeries in the locality and one has an enhanced services contract which allows them to provide outreach appointments at the local homeless shelter, which is geographically close to the surgery.
The practice has close links with the shelter and the charity that runs it. In practice, the patient pathway is often as follows:
- Patient attends the shelter for drop in advice/help or to use it as emergency housing (if eligible).
- Through a combination of outreach sessions (one half hour per week) or signposting from the shelter - a health need is identified.
- The doctor at outreach or the shelter arrange for the patient to register at the practice as either a permanent or temporary patient (depending on their situation). There is no need for ID and the address of the shelter is used. Details of the previous GP are obtained via the patient or through the administrative team.
- A single or double appointment is arranged at the surgery (if necessary extra slots are created)
- The immediate and future issues/needs are identified at the first meeting and follow up is planned to try to build a therapeutic relationship between surgery and patient.
- All surgery staff have had training (from the shelter) about the issues surrounding homelessness, which has helped change how the staff think about the issues and the patients who present.
Record Keeping & Data Collection
Records are kept of how many people are seen at outreach each week and a 'homeless register' of patients is kept for audit purposes. It is therefore possible to track how many patient contacts there have been and also who might be in need of targeted support (such as a care plan). For example, it might be possible to see that a small number of homeless patients are accounting for a large proportion of unplanned A&E attendances. It might then be possible, through liaison with the shelter, to explore the issues further and perhaps put in any extra support or appointments to change that trend.
So, in summary, The Bassett Road Surgery:
- Identified a need and an opportunity for better care for homeless patients in their area;
- network closely with the relevant bodies (especially the homeless shelter);
- created extra headroom and funding through outreach appointments in order to help provide that service;
- clarified their registration procedure for homeless patients;
- and keep records of their activities in this area for review and audit purposes.
The exact way each of the three surgeries operate in their local area as unique as the surgeries themselves but all have gone through a process of identifying and acting on a recognised need through collaboration with their local existing homeless services and their respective commissioners.
We will now move from examples to a suggestion of how you might go about making the case for an enhanced service for your practice, if the need was there.