J R Soc Med 2004;97:170-173
doi:10.1258/jrsm.97.4.170
© 2004 Royal Society of Medicine
Homelessness and health: what can be done in general practice?
Nat M J Wright MB MRCGP 1
Charlotte N E Tompkins BA PGDip 2
Nicola S Oldham MSc 3
Debbie J Kay4
1 Centre for Research in Primary Care, Nuffield Institute, 71-75 Clarendon Road,
Leeds LS2 9PL
2 North East Leeds Primary Care Trust
3 NFA Health Centre for Homeless People, Leeds
4 University of Manchester Medical School, UK
Correspondence to: Dr Nat Wright
E-mail:
n.wright{at}leeds.ac.uk
 |
INTRODUCTION
|
|---|
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.
|
COMMON HEALTH PROBLEMS
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Drugs
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,
guidelines
13 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:
- Avoid concomitant use of benzodiazepines, since co-prescribing is
associated with an increase in drug-related
deaths15.
- Avoid prescribing methadone tablets or injectables in a primary care
setting
- Initial dispensing of methadone should take place under the supervision of
a pharmacist who can observe the patient consuming the medication
- Buprenorphine tablets should be crushed before being taken, under
supervision, to minimize the possibility of street
leakage16
Urine samples can be useful to check that the patient is adhering to the
agreed programme.
Alcohol
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.
Mental health
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:
- In cases of dual diagnosis or where there is a criminal record, involve
psychiatry services. Contribute to the care planning process to ensure
effective integration into health services. If it is not possible to attend a
‘care programme meeting’, then communicate with the care
coordinator by phone or letter to discuss progress
- Foster adherence to medication. In cases of relapse, consider non-adherence
as a possible cause
- Help prevent homelessness by alerting social services or housing
departments where elderly people are showing signs of neglect
- Ensure adequate follow-up for those discharged from hospital
- Ensure that a diagnosis of mental ill-health (particularly
‘personality disorder’) does not lead to exclusion from health or
social services.
|
HEALTH PROMOTION
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Promotion of health to homeless people is fraught with
difficulties
21—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:
- Offer hepatitis B immunization to homeless injecting drug users. An
accelerated schedule (0, 7, 21 days) results in vastly better completion rates
than the usual (0, 1, 6 month)
schedule.23 A
booster must be given at 12 months
- Encourage homeless drug users to use needle exchange schemes, which may
reduce the prevalence of hepatitis
C.24,25
Injecting equipment must not be
shared26
- Beware of death from heroin-related
overdose.15 Advise
the patient not to self-inject when alone and counsel against use of other
drugs, including benzodiazepines or alcohol, with
heroin;15 be aware
of loss of tolerance after enforced or voluntary
abstinence.27 In
future, programmes for homeless people may include peer administration of
naloxone for
overdose.28
|
PRACTICE ORGANIZATION
|
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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).
Working with primary care organizations
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
Working with hospitals
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.
Working with other stakeholders
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’.
User involvement: active or passive?
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.
|
CONCLUSION
|
|---|
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.
|
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INTRODUCTION
COMMON HEALTH PROBLEMS
