Homelessness 1 -Nigel Hewett

Speaker key

IVInterviewer

NHNigel Hewett

NHMy name’s Nigel Hewett. I’m a general practitioner and Medical Director of Pathway, which is a new charity set up to improve healthcare for homeless people. I was talking about the development of the charity, the Faculty for Homeless and Inclusion Health, and then in a separate section, the legal framework under which homeless healthcare teams have to operate in the UK hospital setting.

IVHow can GPs support those who are homeless?

NHThe important first step is to have a welcoming and pleasant response to homeless people. They often come into a consultation expecting a confrontation. So a friendly and warm welcome is an important first step. The second element is to have an understanding of the key problems which affect homeless people and the legal framework in which they’re operating. Often we’re asked for letters for the housing, for example, and it’s important to understand what you can and can’t do with the GP letter, which we’ll go on to discuss.

IVWhat can a letter for housing do and what can it not do?

NHA letter from a GP can be incredibly powerful and really make a difference to somebody’s housing application. But it’s important to understand what you’re trying to achieve with the letter that you’re writing. Most commonly we’re approached to provide evidence to get people more points on the housing register. So that’s simply about making the argument there’s some element of the person’s current housing situation which is detrimental to their health. So, for example, a child with asthma who’s affected by damp and mouldy walls and making that point will allow them to get more points which will give them more priority on the housing waiting list.

The more challenging situation is when a person is homeless or threatened with homelessness. And what we’re then trying to do is demonstrate to the housing authorities that the person is vulnerable and priority need under the 96 Housing Act. And the key thing to understand here is that the arguments you’re making as a doctor has to be heard and understood by a lay person, a non-medical professional in the housing department, and you need to demonstrate why the individual in front of you is more vulnerable than a hypothetical, average, healthy homeless person and why that vulnerability makes them priority need. So the key argument is why the healthcare problem makes them more likely to come to harm as a result of being homeless.

And if you can articulate that argument clearly, that can be very beneficial in ensuring that a single homeless person who might otherwise not be considered to be priority is offered emergency housing.

IVAre there any tips for writing an effective letter?

NHI think the key concept is to understand that you’re writing a letter for a person who isn’t a medical professional and you’re writing for somebody in a housing department who may, frankly, be looking for reasons to decline the request for accommodation. So it’s an adversarial system, often supported by lawyers, in which the usual first step is to turn the person away and wait for them to come back and challenge. So the strongest and clearest letter that you can offer at the first step will be a benefit. And it comes back to what you can say as a doctor which is to articulate the risks associated with the person’s condition and why that makes them particularly at risk of coming to harm as a result of being homeless. So, for example, somebody presenting at housing options might have a discharge letter which says COPD, RTI, GI bleeds. That won’t mean anything to the housing department. But if you are able to say, this person has chronic obstructive pulmonary disease which is a long-term, deteriorating, incurable lung condition which makes you particularly prone to pneumonia; developing pneumonia is a high risk for somebody who is homeless, particularly exposed to cold stress and the stress of being on the streets so I would consider that this person is particularly vulnerable, is at risk of developing pneumonia which is a life-threatening condition and so could come to harm as a result of the combination of this medical condition and homelessness – that is a very hard letter for a housing official to ignore.

IVAre there any particular medical problems that the homeless can develop?

NHYes. I think it’s always important to remember that homeless people are just people. So they’re much more likely to get the things that we have. They’re going to have diabetes. They’re going to have the chronic conditions, arthritis, lung conditions. But amongst the homeless population there is a higher proportion of people with alcohol dependency and everything that goes with that; there’s a higher incidence of drug dependency and more injecting drug use, because if you’re poor, you’ll take your drugs in the most effective way for the money that you’ve got. It makes you more likely to inject, more likely to share injecting equipment, which makes you more prone to blood borne viruses. So there’s going to be more HIV, more Hepatitis C and more Hepatitis B. So it’s important to offer vaccination wherever possible against Hepatitis B and opportunistic screening. Homeless people are interested in their health; they want to take advantage of opportunities that are there. But they have chaotic and complex lives. So the key to offering preventative healthcare for homeless people is opportunistically, when they present. So as they’re reaching across the desk for their methadone script, you need to be reaching back with your hepatitis B vaccination. Give it then and there and they’ll accept it.

IVWhat are the key messages from your presentation?

NHThe key message, I think, is that homeless healthcare is an acid test for our systems in the NHS. It reveals the gaps between health, housing, social care and the voluntary sector. But it’s also a crucible for innovation. So a lot of the newest approaches to vertical and horizontal integration in the NHS are coming from the homeless sector and we are showing that by working together, health, housing, social services and the voluntary sector can transform outcomes for patients which not only changes their lives but actually saves the system money.

IVCan you tell us a bit more about the Pathway model of GP care coordination?

NHThis is a model which was developed here in Camden at UniversityCollegeHospital five years ago. The best analogy would be a palliative care team in which, whichever specialism you had admitted under – medical or surgical – when you recognise a particular combination of healthcare problems, you call to the bedside the palliative care team. That may well involve a wide range of different professionals, may involve GPs and that team will support the patient, the consultants, the nursing team, and have the networks out to plan discharge into the community. A Pathway team works in the same way for a homeless patient. So we can support the patients by access to charitable funds, to get changes of clothes, a new pair of shoes, buy a newspaper – anything that we can do to encourage them to stay in hospital.

And we can liaise with the clinical teams to explain the particular difficulties they may be experiencing: the problems they may find being in hospital, the issues of pain control in somebody who is opiate dependent, the issue of personality disorder which is quite common in the homeless population. Some estimates suggested as many of 60% of long-term homeless patients have personality issues. So helping to mediate the relationships with the clinical teams in the context of personality disorder is really important. And then through a weekly multiagency team meeting, we involve community organisations and develop the networks to help people back out into the community and support them once they leave hospital. So this model has been shown to be beneficial, is generally found to be cost-effective in that we save money by preventing repeat admissions and shortening the duration of stay, with better outcomes for homeless patients. So we now have teams in ten acute hospital trusts from Bradford to Brighton and it’s increasingly being adopted amongst the major teaching hospitals in London as well.

IVWhere can GPs find out more?

NHWe have a website, pathway.org.uk, which provides information about pathway services. There’s a wide range of different publications which we’ve produced with evaluations and outcome measurements. And that’s also a way of getting more information directly from the team. On the website there’s a phone line for information around mental health and homelessness, and our email address, ; it will then be forwarded on to the most appropriate member of the team for a response to any query.

1