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In England between January and March 2003, 31 470 households were newly accepted by local authorities as homeless.1 The large and increasing numbers of people so categorized have complex health, social and psychological needs, and in the past decade numerous centres have been established to provide primary care to homeless populations.2 Personal medical services legislation has made this possible; previously, the system of general practitioner (GP) fundholding was an obstacle to primary care for homeless people with complex problems.3 The new nationally enhanced GP contract will probably offer incentives for care of homeless people.4
What are the existing barriers for this group? In a report to the Office of the Deputy Prime Minister, they included surgery opening times, appointment procedures, location, financial disincentives and discrimination.5 Reasons for discrimination include perceptions that they are migrant, violent, antisocial or ‘undeserving’.6,7 Additionally, we contend that some homeless people face a further risk of exclusion because of their age, gender, ethnic background or sexual orientation. In primary care, challenging behaviour can be an issue, but categorization of an individual as ‘deserving’ or ‘undeserving’ takes no account of the societal factors such as unemployment and poverty that can lead to homelessness.8 The General Medical Council exhorts doctors not to allow personal views about patients' race, culture, gender, sexuality or age to prejudice the care they receive.9 This places a challenge to clinicians not to exclude people from healthcare on account of homelessness or possible drug-using culture.
A comprehensive account of the management of the common health problems associated with homelessness is beyond the scope of this paper. Here we seek to describe the principles of best practice.
Homeless people, in particular rough sleepers, have a higher rate of serious morbidity and mortality than the general population.10 The main health need is drug dependence,5 and the use of illicit intravenous drugs results in multiple morbidity including viral hepatitis (B and C), HIV infection, deep vein thrombosis, pulmonary embolism, septicaemia, encephalitis, endocarditis, cellulitis and abscesses.11 Alongside this, many will be using multiple drugs, most commonly heroin and crack cocaine.12 For drug users in general, guidelines13 make the following points. Controlled drugs should be prescribed to such patients only with objectives agreed between GP, drugs worker and patient. There are now nationally accepted outcomes of drug treatment,14 and the strategy will depend on drug users' individual circumstances—for example, some drug users will request (and have the motivation to undergo) detoxification from opioids; clearly it is then reasonable to work to an outcome of cessation of drug use. For chaotic drug users, such an outcome is not realistic at first presentation and the aim should be to stabilize health and social functioning.This ‘harm reduction’ will include a decrease in the quantity of drugs used, improvement in physical health, less criminal activity and improved family/personal relationships. A substitute prescription of an opioid such as methadone or buprenorphine can help achieve these outcomes. If a maintenance prescription is given, the following points need to be considered:
Urine samples can be useful to check that the patient is adhering to the agreed programme.
Many homeless people have a chronic history of severe alcohol dependence17 with gastrointestinal, hepatobiliary, neurological, cardiovascular or metabolic complications. Not to be forgotten is depression and the risk of suicide.
Commonly the homeless alcohol user will come to the general practitioner with a request for urgent detoxification. This should not be undertaken without adequate preliminary assessment and support. In particular, uncontrolled detoxification can lead to seizures (particularly in the first 24 hours), which can be fatal. The drug of choice to manage withdrawal is chlordiazepoxide. Previously Heminevrin (clomethiazole) was used, but this is more toxic in overdose and has greater addictive potential. A course of substitute vitamins also needs to be prescribed—high-dose thiamine for one week followed by maintenance vitamin B compound strong.
Common mental health problems amongst homeless people include depression, schizophrenia, drug-induced psychosis and anxiety states.18 The direction of the link with homelessness is uncertain: possibly, mental ill-health can be both a cause and an effect.18 Compared with the general population, mental illness is overrepresented amongst young people (particularly rough sleepers), the principal conditions being schizophrenia, affective disorder, psychoses, ‘personality disorder’ and substance (including alcohol) misuse.19 Dual diagnosis is common, and many homeless people with mental health disorders have a history of criminal activity. The offences usually consist of acquisitive crime (to feed a drug or alcohol habit), damage to property or misbehaviour while intoxicated.20
Only a minority of homeless men have a history of violent crime. Less than one-third of homeless people with mental illness actually receive treatment.10 For some elderly people, mental illness is the entry into homelessness. For the general practitioner confronted with a homeless person who is mentally ill, the following principles are helpful:
Promotion of health to homeless people is fraught with difficulties21—not least because the population is so heterogeneous. When questioned, vendors of the Big Issue (who are themselves homeless) gave some priority to reduction of risk from drug injection.22 Here are some practical modes of health promotion in primary care:
There has been much debate over whether primary care is better delivered through specialized general practices working exclusively with homeless people than through mainstream practices.2,29 It has been argued that a specialized general practice for homeless people is ideal to engage homeless drug users presenting in crisis with a plethora of health problems. As well as stabilizing the acute medical state such practices can guide the homeless person in appropriate use of primary care. When these outcomes have been achieved the patient is encouraged to register with a mainstream practice.29 This switch can be difficult not only for patients but also for doctors when there is a strong personal commitment. Therefore, we think that a specialized practice needs the support of a dedicated GP liaison/resettlement worker. Specialized general practices for homeless people are only feasible in large urban areas. For rural homeless populations, the solutions lie in enhancement of existing mainstream primary care services.
Another issue in primary healthcare provision for homeless people is the tension between outreach work and practice-based work. The argument for outreach is based largely on an erroneous assumption that homeless people are transient30 and do not access primary healthcare. Since outreach work is much more time and cost intensive than practice-based work, our view is that it should only be considered in groups where access to treatment is difficult or for a time-limited intervention (such as a course of immunizations).
The Royal College of General Practitioners recommends that homelessness issues should be recognized as part of the core primary care organization (PCO) agenda. In a Statement on Homelessness and Primary Care31 it says that PCOs should provide resources for ongoing homelessness services, acquire a good understanding of the numbers of homeless people in their area and the problems they face, and should promote multiagency links and the sharing of protocols and operating procedures that facilitate integrated working and coordinated care. Historically such co-ordinated multiagency working for the benefit of homeless people has been difficult to achieve, for reasons including lack of clarity about the exact responsibilities and services provided by differing agencies, difficulties in sharing information, and failure to respond in an integrated coordinated way.32
When ill, homeless people seek help later than other people.2 They are over-represented in attendances at hospital accident and emergency departments.33 Whether their presenting complaints would be better managed in primary care is not clear; the reason for many attendances is overdose of medication or deliberate self-harm, so the high attendance rate could reflect the high prevalence of serious illness in this group. The GP will wish a homeless patient with severe illness to remain in hospital until fully fit for discharge, and in a homeless drug user this may be helped by prescription of substitute medication on the ward. The main goal should be to retain drug users on a hospital ward and not have them take their own discharge because of receiving too little substitute medication. Since the GP may wish to continue this prescription after discharge, practices working with drug users need close links with inpatient services. Currently many drug users taking methadone are discharged either without the medication or with sufficient for just one day. This puts undue pressure upon primary care. We would exhort hospital pharmacy departments to work with community pharmacists to ensure that homeless drug users receive sufficient substitute medication, to be taken under supervision, to last them until their appointment with the GP.
Joint working includes not only health partners but also other providers of services to homeless people including housing departments, social services departments and non-statutory organizations. Finally, and most importantly, GPs should seek to work in partnership with homeless people themselves, the ‘users’.
In marginalized groups, patient involvement can be an effective means to better healthcare. In the case of homeless people, isolation, stigmatization and lack of choice present large obstacles.34,35 By involving these patients we can identify gaps in the service and modify practice accordingly.36 Such efforts go some way to counter the social exclusion that contributes to ill-health.37 The underlying principle is that all individuals, irrespective of status, should be allowed opportunities to participate in decisions affecting them.38 To this end, self-help and advocacy groups will sometimes be helpful in identifying important needs.
A pilot study conducted at the NFA (No Fixed Abode) Health Centre for Homeless People, Leeds, aimed to determine the most effective and appropriate methods to encourage and facilitate patient involvement. Thirty patients attending by appointment, randomly selected, completed a structured questionnaire exploring their attitudes to becoming actively involved in the service. The answers indicated that most were interested in influencing the running of the health centre and wanted to be involved in decisions that could affect future recipients of the service. They expressed motivation to make a difference, to pass on their experience, or to ‘put something back’. Some participants, especially those trying to lessen their drug use, expressed a feeling that involvement in the NFA would provide an ideal opportunity to refocus their lives. But the desire for involvement was not universal: some saw no need for change or regarded the NFA purely as a service to supply their medical needs, and a small minority said they did not have the time. These participants favoured a suggestion box to help individuals participate in decision-making but there was little enthusiasm for formal meetings.
In summary, there are now excellent models of primary care service provision to inform the healthcare of homeless people. These models have been developed from working with homeless populations as well as drawing upon best practice developed from related fields such as substance use. Primary care clinicians seeking to offer healthcare to homeless populations have the opportunity to be part of a rapidly developing sphere of healthcare with networks to support both clinical practice and continuing professional development.