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E26 Your Homeless Patients

[00:00:00] 

Vulnerable groups mini-series

[00:00:03] Munir Adam: Hi guys, it's Munir Adam here, welcoming you back to Primary Care UK, and this episode is about homeless patients. Uh, don't turn away, don't disconnect please. You may well be someone who feels helpless about the homeless. That it's not your problem, or even worse, you might even resent having to see them.

[00:00:24] But, as we will be discussing, there are things that you can do in your role as a primary care clinician to make a difference. We should be doing more, but it's not a topic that gets taught often, is it? So this is our attempt to cover that. 

[00:00:39] We're just past the halfway mark in Season 2 of Primary Care uK, which, as you know, is produced in collaboration with Integrated Care Support Services, and a link to that you can find in the show notes.

[00:00:49] Now, the first half of Season 2 was dominated by a theme to focus on ourselves, you know, things like time management, documentation, roles, and opportunities. And for the remainder of Season 2, we want to shift our focus towards those groups of patients who need our services a great deal but will often lose out. Something that is commonly described as the inverse care law. I don't know about you, but to me, it feels like the right thing to do. And that's a sentiment that's broadly shared by the likes of Nelson Mandela, Mohandas Gandhi, and others. That a society is judged by the way it treats its weakest members. So, we hope you'll stay with us as we attempt to do our bit in the next few main episodes. 

[00:01:36] What do I know? What would I know? Not much. The homeless deserve the high standards of care that all patients do, but they often don't get it, because they're homeless. Uh, yeah, that's it. And how would I know more?

[00:02:04] The thing is, in primary care, we get good at things that we encounter a lot, and homeless patients are not that common for a lot of us. And herein lies the problem. Because it's fringe, because at least a lot of us don't see it a lot, we're not that good at it. We don't really understand them. And that's the truth.

[00:02:22] Hence why I was thrilled to talk to someone who does deal with the homeless every day. Two people, even. So, let's join them. 

[00:02:29] Thank you Keith and Carla for joining. It's great to have you on board and what I'd like to do is start by asking you to introduce yourself so that the listeners can understand why I've asked you to come to answer the question about why the homeless should be considered as a separate group in their own right, when we're dealing with them as primary care clinicians. 

[00:02:49] Keith: Thank you very much. First of all, i'm Keith Mcdonald. I'm a GP and Working in the Dr. Hickey surgery, which is a specific homeless GP surgery in Westminster right in the center of Westminster; A stone's throw from the houses of parliament, in fact Okay.

[00:03:04] Carla: Okay. My name is carla borland and i'm an advanced nurse practitioner who's been working at the Dr Hickey surgery for about 13 years now Okay, 

[00:03:14] Munir Adam: So obviously what we're talking about today are the population that are homeless, perhaps the first thing to start with is to think about how big this problem actually is, like how many people are homeless.

[00:03:26] Keith: The first thing to say, I think, is it's very difficult to come, to come up with really hard figures because it depends on how you measure homelessness the The homelessness monitor does measure these things and in 2022, they defined, uh, or they, they measured 282,000 single couples or families who are either homeless or considered to be a threatened with homelessness.

[00:03:50] So if you think about that, that works out, there's probably about 10 per GP in the country. Mm-hmm. Um, so it's a big problem and we will all come across it at some stage in our career. Or in fact regularly during our daily daily work. 

[00:04:06] Munir Adam: So these days there's very few single handed practices aren't there? There's still some of those around and but your average practice size is probably a lot bigger than that and I'm thinking if you've got a practice of about ten thousand then, that's going to be, what, probably closer to 50 or so, but the numbers are still quite small and that's what might worry some people because if you don't have a lot of patients with a particular problem, you're even less likely to be familiar with how to deal with their particular needs, right?

[00:04:29] True. So what are we, what are we referring to when we talk about homeless? Are we talking about just people who just don't have anywhere to live, you know, for a long time or , set a bit of context for us?

[00:04:40] Carla: We're talking about, well, the patient population we have here consists of people who are off sleeping, people who are in bed and breakfast, uh, some kind of temporary accommodation, homeless hostels, sofa surfing, those who live in tents, or the traveling community.

[00:04:59] There's quite a wide range of homeless patients. 

[00:05:03] Keith: Some of them are sleeping in vehicles, and of course, many of the people move from one to another, so they may not be fixed in one type of homelessness. 

[00:05:12] Munir Adam: Ah, yeah. Yeah, 

[00:05:14] Carla: Very transient population. 

[00:05:16] Munir Adam: Okay. Now, I bet that amongst themselves, they might consider themselves to be separate groups and have their own particular needs and... own particular ways of looking at things. But we're going to be referring to this as a whole one group, right, for the purposes of the discussion, because there may be things that they share in common, right? And the main thing holding them together, if you like, in that sense, is they don't have that one fixed place where they live, right?

About Access... and Relationships

[00:05:41] Munir Adam: But, so what? Why do we need to consider this as a separate group to the rest of our population? 

[00:05:48] Keith: Well, the first thing that comes to mind is access to services. The NHS is , is based on residency. So if you can't prove that you're resident somewhere, then technically you're not eligible for NHS services.

[00:06:00] So this is a major problem for many many people and they really can't get registered with a GP even and of course if you can't get registered with a GP then you can't access hospital services and so forth. 

[00:06:12] Um, we see many patients who, who come through our doors and that's what they've struggled with. They say they can't get registered because they don't have documentation, they don't have proof of address, etc. 

[00:06:22] Carla: Definitely, I think we've had our fair share of patients who have tried to access mainstream 

[00:06:31] GP practice, but they've been turned away and this is because the mainstream practice or those who front the reception desk don't necessarily know that most patients or all patients are entitled to primary health care. So they don't actually need to provide any proof or documentation as to who they are.

[00:06:49] Um, and so I suppose why we're, we're succeeding because we have made the access to general practice that much easier. 

[00:06:56] Munir Adam: Right. Yeah. And, and this point was clarified not that many years ago, wasn't it? That we should not be policing them. We're not there for that reason. And it, so it sounds like what you're doing in, at least as far as allowing patients to register is concerned,

[00:07:11] is actually what all GP practices should be doing, is that right? 

[00:07:15] Carla: Well, sure. I mean, for example, to overcome the hurdle of not having a registered address, most of the charities that work locally are happy to offer their address as a care of address, and we also offer our address as a care of address. So there's no reason why a mainstream service couldn't use their property as a care of address.

[00:07:35] And this would overcome many of the obstacles. 

[00:07:38] Munir Adam: Okay, I see. So, right. But. I guess what I'm hearing from that is so in theory they should allow it, but once you allow a lot of people to register who don't have a fixed address, it might create some practical issues that then need to be worked through in terms of correspondence and so on.

[00:07:53] Exactly so, yeah. 

[00:07:55] But even so, as a frontline clinician working in primary care, do we need to consider them differently when they come to us? I mean, what, what is it that makes them so vulnerable? Because this is what this mini series in Primary Care UK is about. 

[00:08:09] Carla: Can I jump in or? 

[00:08:11] If you want to, yeah, yeah.

[00:08:11] I'll just jump in and just say one or two pointed things and then we can hand over to Keith.

[00:08:15] Okay. 

[00:08:15] I think the biggest obstacle is essentially because our patient population have difficulty accessing primary care they become mistrusting of the service and those who work within it. And essentially, I would say our success, or what is necessary for patients, is the option and ability to build a relationship with you.

[00:08:36] And once you've established a relationship, then you can move forward and help them with whatever healthcare needs they have. In the homeless field, it's difficult to transfer relationships to somebody else.

[00:08:48] So for example, if I had a patient, we've built up a relationship over a period of time. I've shared a lot about myself. I'm an open book. They've shared a lot about themselves and we try to find a common ground. Okay, and then once we've established that, then we can move forward, and they can trust me, and I will go above and beyond to help them as best I can, and I'm very honest and open about what my limitations are.

[00:09:12] Essentially, that's it. It's about building relationships, and not having the time pressures which would jeopardize the relationship going forward. 

About morbidity... & potential

[00:09:20] Keith: No, I think that's really all really, really important and uh, I'll just throw out a few figures. Now please don't quote me on the figures because it's very difficult to measure some of these things, but the, the average age of death for homeless people is quoted as being 47.

[00:09:35] Gosh. 

[00:09:35] Now I think that's really for the people who are sort of the more entrenched, uh, rough sleepers, for example. But nevertheless, it illustrates how many health problems there are. Just a few other figures. Um, mental health. In some surveys, up to 80 percent of homeless people report mental health issues of some sort.

[00:09:51] Munir Adam: My goodness. Wow. 

[00:09:53] Keith: Like depression or anxiety as well as more severe and serious mental health conditions. Um, and a few things just from our practice, we've got about... 2,000 patients and Westminster as a whole has something over 200, 000 patients. So we've got 1 percent of the population of Westminster, uh, but we have 15 percent of all the serious, severe mental illness in Westminster, the all patients who've been diagnosed with severe mental illness.

[00:10:22] So disproportionate numbers of people have mental health problems, and actually the other thing is that even for physical health problems we also have much higher figures for things like chronic liver disease about ten times the average for the Westminster, and chronic respiratory disease probably about four or five times the average. So and then not to mention things like hIV hepatitis. 

[00:10:49] Yeah 

[00:10:50] Infections are so much more common in the homeless population.

[00:10:54] Munir Adam: Goodness, that sounds like a lot of work for us as clinicians to have to, well, for you guys as clinicians to have to deal with in the practice. And for us, if we actually take this seriously and do our part. And given the pressures in primary care, I can see why it's very tempting to try and avoid taking on this pressure.

[00:11:10] Keith: I think that's true, but it's also incredibly rewarding because in the end, you know, as clinicians, we want to care for people and we hope to improve their lives and, and that we can do some really very very real Interventions that that will make a huge difference to somebody's life Just for example testing for HIV or hepatitis, and we can offer really effective treatment these days or cure hepatitis one of the consultants comes in from Chelsea & Westminster and he runs a clinic here to treat Hepatitis C and he's had tremendous success with treating really difficult patients.

[00:11:53] Munir Adam: Yeah, I get that. So for example, if you're testing 100 people in a practice for hepatitis and 1 percent of them are likely to come back positive, then you've, you're then going to refer that particular person, right? And they're going to benefit from your intervention. If on the other hand, you're, you've got a different population where you've 10 people out of 100 coming back positive. Well, then you've actually done the same amount of effort, but you've actually helped 10 times as many people. 

[00:12:17] That's true. 

[00:12:17] So there's something about greater returns if you're dealing with people who are more likely to have problems. And it's a more worthwhile use of your time. So I can see why this could be very rewarding, as long as the right support is there.

[00:12:30] Yes. But I want to go back to something you said, Carla, about building those relationships, because that's something that we certainly are very aware of in primary care, and about the importance with any patient to build that relationship of trust. But that must be incredibly difficult if you've got patients who are maybe moving from one practice to another, or moving from one area to another, or do they just always come back and stick to the same practice?

First impressions count... a lot!

[00:12:51] Carla: Well, essentially you have one opportunity, one opportunity to build this relationship and it's generally with the first encounter. And we operate here on a first name basis, essentially. So we are reducing barriers from healthcare as soon as you walk in the building. So it's all first name basis. Keith is Keith. I am Carla. If they want to say Dr. Keith, it's fine. If they want to say Dr. McDonald, it's fine. It doesn't matter. You know, they can call me, whatever. It's all fine. And we sit down, you know, 

[00:13:22] Keith: Sometimes it's ruder as well.

[00:13:27] Carla: That's right. Yeah. And you know, and it's all, all a big laugh. And, um, in terms of building relationships, you've just got to be open, nonjudgmental, you know, pull on your life experiences and some of the things that you've encountered, be prepared to share a bit about yourself so that they can see that there's no obstruction or barrier to get to know you.

[00:13:48] Because they're trying to find a way, that they can find a level ground or a level playing field. And then you just sit there and you talk. Generally, for the first 10 minutes, they're probably just having a conversation. And then after that, we will move forward and decide what all the problems are. And then we will work together and prioritize what the problem is. What problem do we tackle today? 

[00:14:08] But sometimes they don't come back. So that's why you need to... show them that primary health care or engaging with clinicians is not as daunting as you think. You know, so hopefully if they don't come back, they will have the confidence to move to another service and be able to reestablish another relationship.

[00:14:27] So it's time consuming, I would say, but you invest the time at the beginning and then afterwards it just gets easier and easier. So initially when you come in and you may see me, depending on what clinic I'm running, if it's your first encounter, you could be with me for half an hour, maybe even longer, but then when you start coming and coming again, it could be just five minutes or 10 minutes.

[00:14:48] So it just, it really does benefit the patient and our service if we invest the time at the beginning. 

[00:14:55] Munir Adam: I love what you say there about the minute they come in through the door, they're calling you Keith or they're calling you Carla. So is that more to do with perhaps taking away the hierarchy that people might feel as part of the process of establishing that connection?

[00:15:08] Am I understanding this correctly? 

[00:15:10] Keith: I think that's very true. Um, I think one of the problems that many homeless people feel is that they all find is that there are lots of places where they get either a poor reception or they get knocked back. I mean, they'll often have encounters with police, for example.

[00:15:28] I'm not criticizing any particular group, but their interactions with authority are often quite negative. Many of our patients will say that they really, really don't like going to hospital, and in fact, they'll refuse point blank to go to hospital. I think what we try to do here is to try and accept people as they, as they are, as they present.

[00:15:48] And there's a, a lovely story that I often quote. A wonderful practice manager had a bit of a, a difficult time with somebody at the front desk who was complaining about something or other and started to become a bit shouty and, and causing all sorts of problem. And the way she did it was said: would you like a cup of tea?

[00:16:06] And he said, oh, two sugars please. And suddenly the whole thing diffused. And then afterwards you could have a proper conversation with him. And it was just because of all that frustration that had built up in him, was coming out at us. Even though it wasn't our fault, but the cup of tea sort of resolved the problem.

[00:16:24] Munir Adam: Wow, brilliant. That's amazing. 

[00:16:28] Keith: That sort of encapsulates for me, the approach of the practice. And I think that that's why it's such a, uh, a valuable service really. 

[00:16:34] Munir Adam: Gosh. And I bet it was not just the patient, but everybody concerned there probably felt better after that cup of tea. Yes, I think 

[00:16:42] Carla: that's true.

[00:16:42] Brilliant. Oh, yeah. I mean, we do offer everybody a cup of tea when they come in so that they can sit down and relax. And sometimes it depends, it could be baked biscuits or sandwiches on offer. And they're quite happy about that, so. 

Specific needs... specific approaches

[00:16:53] Munir Adam: Okay. Can you say a little bit more about what is different about this group that we should bear in mind?

[00:17:00] Keith: I suppose it's the... In many ways we've covered some of it, they're very unstable lifestyles, so firstly they don't have an address. Secondly, their phone numbers tend to change a lot. They'll either lose their phone or their phone gets stolen or change their phone number. So it's very difficult to follow up, you can't rely on regular forms of communication.

[00:17:19] Email is probably good, if they've got one, and if they check it. But again, they don't get access to these services a lot of the time. So, one of the problems I think is that If you want to follow up somebody, you need to give them a very clear path to get followed up and they need to feel welcome that they can come back again because you're not going to phone them and you're not going to send them a letter to ask them to come and check their results, for example.

[00:17:44] Carla: Yeah, I'd say that, for example, in terms of, um, they not having a suitable address and we are a care of address, it helps us to be involved in their ongoing care, especially when we have had to refer them into secondary care. So if they're using us as their care of address, we'll do a referral. All their correspondence will come back to us.

[00:18:03] We don't open any of their mails, but we keep it in a box. And they know that they can come back every week or every two weeks to check if any mail has arrived. Once they arrive, they open the letter, and if it says anything about hospital appointment, they will then want to see us to discuss it.

[00:18:19] We'll confirm it, or we'll go online and confirm the appointment for them. We'll do the communication with the hospital for them. So we wrap it all up. We take care of everything to the very end, you know, and even if we have to, we'll arrange transportation or a peer advocate to take them to the appointments to accompany them, you know, to help minimize anxiety or sometimes the practice manager depends on how anxious or stressed the patient is, the practice manager may even accompany them to the appointment once in a while. 

[00:18:49] So, you know, we, I think we provide the wraparound care. 

[00:18:52] Munir Adam: Right. Okay. So let me look back to some of the things that you've said, because there's a lot of really useful information coming here, something about, first of all, difficulty with communication, because they don't necessarily have a mechanism by which you can get in touch with them if you need to.

[00:19:07] And so when they do come, the last thing you want to do is make them feel like they're unwanted or unable to get through. Sorry, we're full. We haven't got any appointments. Go away, is the kind of answer that often, unfortunately, receptions have to give. Somehow, despite the pressure of general practice, this is somebody who's made it to your door. You may not be able to get hold of them if you send them away on this occasion. 

[00:19:29] It's really something to think about. And then a practice can do much more by actually being the advocate, being the helper, accompanying them to their appointments, as you mentioned. Wow. And This is a population who are likely not to necessarily trust the services you were saying.

[00:19:47] And yet, on the other hand, Keith, as you mentioned, they have multiple problems. They have all of those additional high level morbidities and things. So these are the ones who desperately need the help. And yet they're less likely to want to access it. They're less likely to be able to access it. And then when they do try to, sometimes a practice will be as harsh as saying, you haven't got an address, go away, we can't register you.

[00:20:06] Keith: You've summarized it very well. 

[00:20:08] Carla: There has to be some flexibility. I mean, even our clinics are generally full all the time, but if somebody shows up at the front desk and wants to be seen, one of us would accommodate the request. Sometimes, they may say to reception what the problem is, but when they come into you, it's not actually that.

[00:20:27] And it may be that they just needed to sit down to have a conversation with a friendly face. They may not walk out with a prescription, but they just may walk out with some, some hope. Or, They'll walk out with something feeling as if that they were listened to, so we're all very flexible here. 

[00:20:43] Munir Adam: , Because you mentioned this point a couple of times in different ways, I think it's so wonderful. I, I will just say it again, which is they come and when they leave, they feel good. You've given them something, even if it's not a prescription, because of how society sees, sees them. And, and, you know, going back to a cup of tea, that's a very strong message of, well, respect, uh, love, affection. I don't know, whatever it is, um, and as you say, it can actually be a powerful way of diffusing what might otherwise escalate into a difficult situation. 

[00:21:11] There's a lot we can learn just by reflecting on some of the things that you're saying here. Is there anything else more you can say about what a practice can do?

[00:21:18] You know, what can be done at a practice level to try and help, help these people? There's a lot of wonderful things you're doing, but for the average GP practice? 

What Practices and Clinicians can do

[00:21:25] Keith: Look, it's, it's very difficult because the time pressures are enormous and look, I'm the first person to say that GPs are under huge, huge pressure and we are privileged in, in this practice in, in that this is the way we work and our patients are very tolerant of long waiting times sometimes, because they accept that that's what happens.

[00:21:44] And that isn't so easy in regular GP practices. That's the background. What can you do? I suppose if somebody is known to be, for example, homeless, and they have these particular needs, and they are difficult, maybe the Practice could flag up that person as being, in inverted commas, a special case. That you could make an extra provision for or try and, you see a lot of the time, as Carl was saying, if you, if you missed that opportunity, you might actually have missed something quite important. It might not be, but it might be. And it might be the last time that they present for six months. Who knows?

[00:22:23] And so therefore, if you can just at least deal with that immediate problem and then say, well look, I can't help you with everything, these problems are not easy to solve. But let's get you back next week and make them feel that they're not being rejected. Yeah, 

[00:22:36] Munir Adam: And it's not difficult to put alerts in, in most computer systems, so that somebody does turn up.

[00:22:41] And there are alerts, but perhaps to a large extent, they're probably more driven by the kind of things that general practices are told to focus on. You know, if I can, if I can say it in that sort of way. Yeah, 

[00:22:52] Carla: I think so, yeah. I've got two suggestions. So, the first one I learned early on when I started working in homeless healthcare is not to encourage dependence; they don't appreciate that.

[00:23:04] And so, for example, if somebody presents who has a wound or a long standing ulcer or anything like that, telling them they should come three times a week or every week is never going to happen because their lifestyle doesn't enable them to do that. They're transient. They could be sleeping in Victoria one night and could be up at Southend the following night.

[00:23:25] They want independence. You teach them what to do. You explain the rationale for it and you give them the dressings and off they go. You let them know that you're here. If you need me, call me, or pitch up and see me, and they will do that, and they appreciate that. And I learned that because when I was new in the role here, I went off for two weeks, I told them somebody's going to cover me, and none of the patients showed up, and when I, when I came back, I said, why didn't you show up?

[00:23:52] You've not been here for two weeks. They said, I only want to see you. Then I realized you can't transfer a relationship. So that's the first thing, and they don't want you to encourage dependency. They want to be independent to look after themselves, so that's the first thing. 

[00:24:07] The other thing is, for the mainstream service, I think it would be nice if you've got your triage arm and you've got your routine daily clinics, but it would be nice to have another arm which is a slow lane, and for patients who are complex. They go down in the slow lane. 

[00:24:22] And in the slow lane, for example, all of us do exactly the same things. We take bloods, GPs and nurses do dressings. We do everything here, and that's all about building the relationship. It helps us to maintain our skill set. And we are showing care and compassion for the patient.

[00:24:38] We're not bouncing them from person to person. Okay, go to the phlebotomist for the blood test and go there to the nurse for that. We all do it here. So, and they appreciate that. 

[00:24:49] They appreciate that we are caring for them from beginning to end. So I think it might be nice if you had a homeless patient or a complex patient on your patient list who could do with the extra time and care.

[00:25:00] And you do everything for them in that slot. It doesn't matter how long it takes you, but once you've dealt with everything, you know that they're not going to come back frequently because you've invested that time in the beginning. Then the future appointments could be five or ten minutes. 

[00:25:15] Keith: Another suggestion, um, particularly this is for the patients who aren't registered, for example, and they haven't got the correct documentation and so on and so forth.

[00:25:23] Um, why not just see them as an immediately necessary? And then you, there isn't a sort of a longer term commitment and then you, It gives you time to check out documents if necessary and so on. 

[00:25:34] And another quick anecdote uh, this was a young lady who was working and didn't really fit in the sort of typical homeless profile, if I can call it that.

[00:25:43] Um, but she had tried to go to many GPs because she had abdominal pain and in the end turned up in a homeless practice, which was completely inappropriate, really, given her circumstances. It turned out she had a big tumor in her abdomen. Oh, fortunately turned out to be benign, but nevertheless I think she'd been trying to get treatment for it for about six months, but because she didn't, she'd been told you shouldn't go to A& E for just anything.

[00:26:10] Yeah. 

[00:26:10] But she couldn't get into a GP. 

[00:26:12] Oh no. 

[00:26:13] Immediately necessary sometimes can be a useful tool. 

[00:26:17] Munir Adam: These kind of examples scare me because when you mention an example like this it makes me think there must be so many others. 

[00:26:24] Keith: Well, I think there are many, many examples of this type, yeah. 

[00:26:27] Carla: Yeah, you've definitely got to advocate for the patients.

[00:26:30] I've sent a few patients into A& E because I've had concerns, and they've been turned around as soon as they've gotten in there. And, you know, you have to phone back A& E and tell them, this is the reason why you want this patient to be seen. I remember I had a guy, and I sent to A& E, he was, um, had a fever, had these weird spots on his body.

[00:26:51] It just didn't seem well. I sent him into A& E, his bloods came in, they were all deranged. They sent him away. I phoned A& E and demanded that he go back. He went in, they diagnosed him with meningitis, a hole in the heart, Hepatitis C, and something, oh, and something else. Yeah, and it was crazy because our patients Yeah, 

[00:27:12] they don't fare very well.

Discrimination... and dangers of zero tolerance?

[00:27:14] Munir Adam: This makes me think of, don't know how true it is, but the possibility that sometimes without realising we're discriminating against these, it's very easy because they can't necessarily speak up for themselves and they might not articulate themselves as well as somebody else might. And I'm not saying that's what happened on this particular occasion in A& E, but it certainly could be the case.

[00:27:34] Keith: Well, I'm glad you brought that up, because I think that's a really, really important point. There's all sorts of reasons. Um, there's language, um, there's the way people look, the way they smell, the way they behave. Um, and I remember hearing somebody who'd been a long term street homeless. And they said look, the way we speak is how we learn to protect ourselves on the street. 

[00:27:55] So if I come in and I swear, that's my protection mechanism. That's how I survive on the street. Right. And so then they bring that into, for example, a hospital. And then immediately they'll be thrown out. Because zero tolerance, which I understand. But I think we have to... make allowance, I suppose, because of the statistics I threw out earlier on about mental health problems.

[00:28:19] So if somebody has a mental health problem and they've got a physical health problem and they can't articulate that very well because of their mental health issues, then yes, it's very easy to discriminate against that person. 

[00:28:34] Carla: I was going to say, fortunately, over the years, there have been ways that we have managed to make some improvement with the secondary care experience in terms of,

[00:28:42] there's a homeless health team, particularly in St. Thomas Hospital, and we've got good relationships with them. King's College have one, and is it St. Mary's? St. Mary's have a homeless team. So if we're sending in a patient who we know could be quite complex, who may not want to stay, we can contact the homeless team in the hospital, let them know that we've sent this patient in, and they can go down to A& E and advocate for them and support them while they're there.

[00:29:07] So you can tap into those types of resources. 

[00:29:11] Keith: Yeah, I think just for clarity, I'm not criticizing other, other organizations. In a sense, we can make our own rules here. We can allow behavior that wouldn't be acceptable in a hospital. I think it's a very different situation in the hospital. As Carla says, that's why we try and advocate.

[00:29:27] Carla: Just one more thing, for example, just like I sent a gentleman into A& E yesterday and I wrote the referral letter for the hospital and then at the bottom I wrote, um, registered homeless patient who, who will require additional support. So I think when you're sending letters into the hospital with the patient, you just flag that up and then you know that the clinician then is going to give them a lot more time.

[00:29:49] Munir Adam: That's such an easy thing to do. Yeah. Yeah. Probably wouldn't have really crossed one's mind often, it doesn't, does it? Because you're referring somebody and you're thinking about their clinical problem, not necessarily their social circumstances. In fact, that's often the last thing one thinks about when you're sending somebody to A& E is the social side of it.

So the homeless walks in through your door...

[00:30:06] Munir Adam: And yet you've pointed out why that's so important. Okay, so you've got a homeless person, they managed to get through the front door they managed to register and they managed to get an appointment and I'm the primary care clinician, they've come to see me. Hopefully, I'm somebody who's had a listen to this podcast episode and they'll get more aware.

[00:30:25] But what are some of the things that I, just like maybe a dummy's guide to how to manage the patient who walks in through your door and you know they're homeless. 

[00:30:34] Carla: Well, I think if they're going to come in and see me, the first thing I would ask is, um, well, first of all, you want to know why they're here. Are they going to say, then you want to understand how they became homeless.

[00:30:45] So you start asking those types of questions. How long have you been homeless? They will say six months. Where did you live prior to that? Then you start to burrow down. Was it council accommodation, housing association, or were you living with a family? living with a family, why are you no longer with a family or relationship breakdown, then you have a better understanding.

[00:31:04] But you don't want to project your own feelings of what a family breakdown means to you onto the patient. You then want to work out what does that mean for the patient? Yeah. And then, so after you've done all of that, they will tell you where they're staying. It's very important to check if they're ex military, because if they're ex military, they get taken off the street pretty quickly, because there's a charity down the road called Veterans Aid.

[00:31:28] Okay. Veterans Aid, they'll give them their, um, military number. They will check it with the Ministry of Defence, and they'll be off the street that day. And then after that, you, um, do their basic observations, talk about allergies and things, and then you take care of their requirements. 

[00:31:45] Keith: That's absolutely right.

[00:31:46] And I think the other thing is that, um, as clinicians, we're trained to look for disease and to try and treat disease. And what we have to remember is that somebody who's not got a home, that, that disease comes pretty low on their list of priorities. 

[00:32:02] Oh, that's true. Yeah. 

[00:32:03] Where they live and how they're going to survive tonight is much more important than their hypertension or their diabetes or whatever other problem they might have.

[00:32:12] even cancer comes low on on their list of priorities until they're diagnosed with cancer, which suddenly it becomes, then it becomes very, very significant. But the process of, for example, having, uh, investigations into cancer is pretty low on many people's lists. 

[00:32:29] Munir Adam: Well, so how do you work around that then? Because I can understand why it's low on their list, but it is important still, isn't it? 

[00:32:34] Keith: It is important, exactly. Um, well, I think that that's why what Karl is saying is very important, is that it's really important to understand where somebody's coming from, because until they... Understand that you know and you can, you can empathize with their situation.

[00:32:48] We might not be able to do very much about it, but it's important. They need to believe that we are concerned about that. And it might just be giving the letter for housing or it might be giving something really quite simple, but that we've taken it seriously and here's what we can do to help. And we can send you along to one of the homeless charities, for example, so that they can help you with their housing. Now let's talk about this, um, rectal bleeding that you, you mentioned to me. 

[00:33:14] We have to do it in that order, really. Otherwise, it's, it's an non-starter. 

[00:33:18] Carla: I think. I think it's not uncommon for you to hear one of us say to the patients we are really, I'm really worried about you. Yeah. It's, it comes out of our mouth all the time.

[00:33:27] I'm really worried about you. Yeah. I don't want anything to happen to you. 

[00:33:32] Munir Adam: So what I'm hearing loud and clear from you is that building that relationship and actually giving them time taking an interest in their concerns What their reality is actually And giving them the opportunity to actually talk about those so that you're showing you're interested in them And and that you may be able to do something to help them with that possibly, then they're more likely to open up and actually listen to what might be considered traditionally the clinicians agenda Yeah. You know, whatever that might be in terms of their medical problems and focus on the social history and acknowledging and building that relationship. 

Opportunistic testing... & what it might achieve

[00:34:04] Munir Adam: Is there anything from a more of sort of medical model side of things in terms of their actual health? You mentioned early on towards the beginning, Keith, that they have more morbidity, they're more likely to have those sorts of conditions.

[00:34:16] Can that be picked up earlier? Should we be doing more? 

[00:34:18] Keith: Uh, well yeah. And I think that we shouldn't be disheartened really, I mean, because it sounds like it's a very challenging process, but actually we have found that people, once they start to understand their medical problem, let's put it that way, and we, let's, let's say we've got, we've got beyond the sort of the housing issue and so on, but once people do find out about diabetes or the hypertension, we've had some remarkable results, and we've had people reverse diabetes.

[00:34:43] Wow, really?

[00:34:44] Lost a tremendous amount of weight, and if they've, their cholesterol has normalized, their blood pressure's come down. So. You know, we do get an awful lot of what I would call medical success stories where people who it would have been very easy to write off as a bit of a no hope really, but in fact they've made a complete reversal of their deteriorating health.

[00:35:07] Munir Adam: That is really encouraging. Because it's true, it's very easy to write people off like that, as in, it's not worth trying, they've got, actually for the reasons that you mentioned earlier, because they've got other priorities, so why am I even bothering to talk about their cholesterol of 5. 7, when this person is actually wondering where they're going to get their next meal from.

[00:35:26] But actually, adopting that attitude is just going to mean that you, you're losing the opportunities when you can make tests to do something about it. 

[00:35:34] Keith: One of the best examples, of course, is Hepatitis C. This is predominantly in the IV drug users. And, you know, again, it's a, it's a group that often gets written off very, very easily because, you know, they're, they're a drug user and they're on the streets.

[00:35:47] Um, but the vast majority of our hep C patients get treated, successfully treated. So, you know, and this is a major health, um, success really. 

[00:35:59] Munir Adam: So this brings me on to actually the point I was thinking as you were saying this. Should we be investigating them or examining them perhaps differently to somebody else, because of the different prevalence?

[00:36:11] Keith: Without doubt, yes. The things that are common, I sort of mentioned a few of them, but mental health is one, so definitely explore that. Because often there are hidden symptoms that don't initially manifest. A lot of psychosis and schizophrenia are things that might be not immediately apparent, but once you get to know somebody a few times, you start to build up a picture of that. So I think that's a really important one.

[00:36:38] The other things, respiratory disease is incredibly common, and it's underreported by the patient. So that, you know, I'll... sees people, and Carla as well, and they walk in and they're evidently breathless, and you can ask them, how's your breathing? Oh, it's fine, it's normal.

[00:36:54] So, so there's that uh, hypertension, diabetes, it's, it's always worth checking diabetes because we have quite high, you know, and, and yeah, the alcohol, and always, always ask about alcohol and drugs. Right, yeah. And also, not to forget. It's not just the heroin and the crack, it's now things like pregabalin and, uh, pregabalin and gabapentin are big, big problems.

[00:37:15] Munir Adam: Oh, you mean getting abused? 

[00:37:17] Keith: Abuse of them. I call it the new benzo. It's basically... Oh, is that right? Behavior of people who are on pregabalin or taking pregabalin is very much like the benzodiazepine users. 

Challenges & good memories

[00:37:27] Munir Adam: Hmm. Well, look, you've both been doing this for quite some time now. You mentioned it being a very rewarding thing earlier on.

[00:37:34] Doesn't it get challenging sometimes? I can't help but think this must be quite tough. Yeah, come on, don't tell me it's not tough.

[00:37:45] Carla: Yeah, What makes it tough? I think definitely not inside the surgery. I think we are all singing from the same hymn sheet. We're a small team. We are all following the same, the same processes. The challenge comes when we're having to engage with an external service and there are those barriers that we have to navigate for the patient.

[00:38:06] I remember when the GDPR first came out and I was trying to book an appointment for the patient. And I was told by the, uh, the person on the other end that I couldn't make the appointment or secure the appointment for the patient because of GDPR. And the patient is sitting right next to me and the patient doesn't have a phone.

[00:38:25] And that was a big frustration. And if I, as a healthcare professional, I'm struggling, how are the patients going to get through? 

[00:38:31] Munir Adam: Well, they'll just give up, isn't it? That's it. Yeah. 

[00:38:34] Keith: That's true. And, um, look, we're all human as well. You know, many of our patients, I'd say the majority of them are just a pleasure really to deal with.

[00:38:42] Yeah. But we do get some very, very difficult patients indeed. And I'm afraid that's life. And you still maintain your professional approach, hopefully. That's a, that's a real challenge. And that can be, that can be hard. 

[00:38:56] Munir Adam: And that's going to be general practice, you know, even if you avoid the homeless, you're still going to have some to appreciate, and there's going to be those who you don't necessarily look forward to. 

[00:39:04] Carla: I mean, we did have, um, one patient who was particularly challenging and one of the clinicians here volunteered themselves as the go to person. So the patient was only booked for that particular clinician. And even though everyone felt sorry that, you know, for them, they were quite happy to not have that patient on their list.

[00:39:25] Munir Adam: You mean felt sorry for the clinician or for the patient, I imagine as well.

[00:39:32] Keith: There and we're all under. time pressure as well. And so all of those things, it was, and Oh, the other thing that personally could frustrate me sometimes is there's somebody that you've tried to do an awful lot for, and then they don't turn up for appointments to the hospital or they, you know, and you know, it's important.

[00:39:48] And it may be even like sort of a potential cancer or something like this and they don't turn up to their appointment and I think the hospital must find that incredibly frustrating as well. 

[00:39:57] Munir Adam: Yeah. Well, thank you for sharing that. And I wanted it to just come out because I like to try and see things in an optimistic and positive light.

[00:40:04] And it really is, but that is the reality of it, that there's going to be difficult encounters and things and where you'll go over and above and really trying to help and you feel that it's not necessarily paying off because of external barriers, either the patient, the homeless person, or because of other services, they don't see things in the same way, or they have their own policies and protocols that they have to follow, all of which, you know, there's good reasons for, but not necessarily allowing this person to advance or not showing the flexibility that you would like them to. 

[00:40:31] But that's enough of the negative. Let's come back to positive again. So I'd like to ask each of you to tell me just one example of something that you found rewarding, positive, one experience.

[00:40:43] Carla: I had a gentleman who um, was placed on anti psychotic medications for a few years and then he became diabetic, had an insatiable appetite and had lots of immigration issues. We changed his antipsychotic medication, talked about his diet and his weight and everything. And he came in and he asked me, he said he doesn't want to have diabetes anymore. What could he do? So we talked about food options, but you have to remember they don't have. A great choice of food is mainly carbohydrates out there. Yeah, so 

[00:41:17] Munir Adam: Healthy food is expensive 

[00:41:19] Carla: That too. Yeah, so we talked about portion sizes and things and in the end I thought you know something he's not going to have any control over portion sizes. So let's focus on exercise So I made lots of different suggestions. Why don't you get off the bus two stops before your destination and walk, but walk with a greater pace. I got down on the floor and showed different types of exercises to do. 

[00:41:41] Munir Adam: Oh, wow. Okay. 

[00:41:42] Carla: And and he focused, he focused on reducing his waistline and then before you know it, I think it was about six months later, he reversed his diabetes and it was absolutely wonderful.

[00:41:50] It's like a big celebration because he was that determined to get rid of it. And I think the motivation wasn't necessarily getting rid of the diabetes. It was reducing the amount of medication he was having to take. 

[00:42:01] Munir Adam: Gosh, don't don't build kind of experiences. Just make our job worth doing. 

[00:42:05] Carla: Yeah. So that, that was, that was quite nice for me, actually.

[00:42:09] Keith: Uh, a lot of the time I think to myself, we don't know what happens to a lot of our patients because if they move or they go somewhere else, then often never hear from them again. And one patient I remember. He came and registered with us. His relationship had broken down.

[00:42:24] He was drinking incredibly heavily. And he was another gentleman who came in and obviously had a chest problem and he had quite severe COPD. And he was pretty desperate at that point and he, he was frankly suicidal. And we helped as best we could with these various problems. And then he sort of disappeared.

[00:42:44] And then about probably a year later... I was just in the streets somewhere in the center of London, and he said, Oh, do you remember me? And he told me basically his life had completely turned around he'd got a job again and he was back working and he said and he just said thank you so much because he said if it hadn't been for you, then I wouldn't be here anymore.

[00:43:05] Munir Adam: Oh, fantastic. 

Where to get help

[00:43:08] Munir Adam: Just to round off then, mention some useful resources that you might want to direct people to as well. That, and then maybe some take home points. 

[00:43:17] Carla: Well, I would contact voluntary services that focus on homeless healthcare. So here in Westminster, we have a handful of those. So in each borough, there should be one.

[00:43:26] There's generally a GP practice that has a large homeless population, within each borough, you can also tap into them to find out who they liaise with. Um in the hospitals, you'll find the homeless health team, so it would be good for you to contact them. And then also you've got services, alcoholism, you've got CGL, you've got Turning Point who do drug services and alcohol services.

[00:43:47] You've got Doors And then you've got the crisis team. So it's good to also know what provisions are in place for homeless people in Christmas, around Christmas time, and you can refer them to those services. So Crisis, they're generally open for several days over the holidays, and they have all sorts of services in there, they have barbers, healthchare, everything's in there all sorts of services So, oh, and you could tap into your homeless hostels, because they'll have all sorts of services you can tap into, as well, or information that you can use. The information is there, you just have to go looking for it. 

[00:44:23] Munir Adam: Brilliant. Thank you. 

A few take-home points

[00:44:25] Munir Adam: Okay, final take home points. 

[00:44:28] Keith: When I was thinking about this, I thought of a few. The first one, I loved what Jacinda Ardern, the former New Zealand Prime Minister, said during COVID: be kind.

[00:44:38] And, and I think that that sort of encapsulates it. For homeless people, you might, may be the only person in their life who's ever kind to them. 

[00:44:46] Oh, yeah. 

[00:44:48] Especially for, for, um, rough sleepers. They, they have a really, really difficult time. And they don't really... Even their friends, in inverted commas, aren't friends because if they have an opportunity to rip them off, then they will certainly do that. So they're acquaintances, but then they're certainly not friends. 

[00:45:05] Harsh reality. 

[00:45:06] Paul O'Reilly is our wonderful senior partner here and he has an expression that says that homelessness is a fundamentally a disease of relationships, and this goes back to what Carla was saying is that in order to become homeless, you need to have destroyed pretty much every relationship, significant relationship in your life.

[00:45:26] And that's how you end up homeless. And that's why what Carla was saying about building relationships with people is so fundamentally important because many homeless people have no significant close relationships ever in the world, . 

[00:45:40] Yeah. So, um, and the the third thing I was gonna say is that you really can make a difference to people. And so you know, yes, it takes some effort and, and it will need a bit, especially at the beginning, more time and some patience I suppose. But it, it's incredibly rewarding and you can make an enormous difference to someone's life. 

[00:45:59] Carla: Yeah. There's one thing that we do here, which I don't see many practices do, is we have pictures of our patients on their records.

[00:46:07] So when we open their records, there's a picture of them there. And I think that's for several reasons. One, you can see progress when they've transitioned or they've gone, you know, they've done brilliantly. You can compare the pictures and you can look at them and talk about it with the patients.

[00:46:22] We also use their picture to provide ID letters if they need it, if they're trying to open a bank account. In addition to that, you also have to remember that the patients, as Keith said, their friends are acquaintances and they know everything about each other. They talk openly about their family lives, their medical lives, everything.

[00:46:42] And there have been times that people would present here pretending to be somebody else. But because we know, we've built a relationship and we know who that is, but the reception may not necessarily know. So there's a picture of that person on the record. So you know that you're definitely talking to the right person.

[00:46:59] Munir Adam: Ah, yeah, that's useful. That's great. Thank you very much, . Keith, Carla, fantastic to have you and really interesting to hear your experiences and the advice. A lot of which I have to say is definitely possible to implement, even in your normal, if I can use that word, General Practice and in normal consultations as well.

[00:47:20] Yes, we need to spend a little bit more time initially, as you said right at the beginning, Carla, to start building that relationship, but then we can make a significant difference because these are people who desperately have needs that need to be met. So fantastic. Thanks both of you. Thanks for joining.

[00:47:34] Carla: You're welcome. Thank you very much.

[00:47:35] 

[00:47:35] Munir Adam: That was great, right? I mean, sure, not every practice is going to be able to implement all of the things that a dedicated to homelessness practice can do, but there were certainly bits of information, knowledge, and just insights about how we can do things differently, and I hope that you're taking away some useful stuff that you can implement, too.

[00:47:57] And it wasn't even just that. There's something about certainly for me, about an attitude, about being opportunistic when I do come across my next homeless patient. I'd like to be able to make a difference for them, and I'm sure that you would too. There are some links in the show notes as well. And you can let us know what you think of this episode on Apple Podcasts or Spotify or wherever you listen, or using the show note link as well.

[00:48:26] And join us again next month as we continue the series and embark on another topic which relates to the theme of inverse care law. But that's it for today. Thanks for listening. And until next time, keep well and keep safe.

[00:48:39] Music]

Disclaimer

[00:49:02] Munir Adam: Primary Care UK was developed by Therapeutic Reflections Limited to inform, educate, support, and unite the primary care workforce. Specifically, it is not for the general public or patients. All information and advice contained therein is time, location, and context dependent and is general advice only.

[00:49:19] No guarantees are provided with respect to the accuracy of the content. The hosts, contributors, and the organizations they represent do not accept liability for any actions, consequences, or effects that result directly or indirectly from the content provided. Please refer to the episode description.

[00:49:35] Thank you for listening.