Keeping homeless patients off the streetsBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i318 (Published 19 January 2016) Cite this as: BMJ 2016;352:i318
- Anne Gulland, freelance journalist, London, UK
When Paul Wilson was discharged from hospital after surgery to repair a torn ligament hospital staff put him in a taxi and sent him home. Home was an alleyway near the Strand in central London.
“I had a bag of morphine tablets and a letter to show the police why I was carrying them, but that was it. The staff told me to go home and put my feet up. They knew I was homeless so how could I do that?” he says.
Wilson, now working as a homelessness consultant, says his story is typical of what many homeless patients experience on discharge.
“The treatment and care I got in hospital was fantastic but it was a busy hospital and they didn’t want to keep me in there any longer than they needed to,” he says.
He hears stories of doctors and nurses bending over backwards to keep homeless patients longer than necessary and mentions a homeless friend whose doctor ordered radiographs at midnight, just so he could be kept in hospital an extra night.
“You need a system in place where the hospital can make a phone call and talk to a dedicated person who knows housing law and knows the system. It’s not the doctor’s job to find a bed for a homeless patient,” he says.
This frustration at not knowing where to turn was experienced by Pippa Medcalf, a consultant physician at Gloucestershire Royal Infirmary, who became so fed up at having to discharge homeless patients on to the streets that she contacted a local homeless project, the Gloucestershire Emergency Accommodation Resource, to see how they could work together. They won a £26 000 Department of Health grant to run a six month pilot, paying for a nurse and a housing officer to find a bed for homeless patients on discharge.
Time to heal
“I couldn’t bear to send another person out on to the streets,” says Medcalf. “We didn’t dare ask people where they were going because there was nothing we could do,” she says.
Once the team had received the money the project, called Time to Heal, was fairly straightforward to set up. It was a question of putting up posters around the hospital and informing and educating staff about the new service. The team has also educated staff on identifying a homeless patient. Although some may have the letters NFA (no fixed abode) on their notes, others could be sleeping on friends’ sofas or living in a squat.
“I tell doctors that if they suspect a patient is homeless they should just give me a call and I’ll come and assess the situation,” says Steve Pankhurst, the housing officer working on the project.
In a small survey carried out before the service was established seven out of 12 homeless patients were discharged on to the streets: one to a car, another to a shop doorway. An evaluation of the project’s first year—November 2013 to October 2014—showed that the service has reduced a patient’s average length of stay from three and a half to two and a half days. Medcalf puts this down to the fact that before the project doctors would keep suspected homeless patients in longer “while they worked out what to do with them.”
“When the service was introduced the staff were thrilled that they finally had a solution. Everyone has embraced it,” says Medcalf.
In its first year some 113 patients came through the project, 76% of whom were found accommodation on discharge, compared with none the year before. Just over half (56%) were of no fixed abode or sleeping rough and 44% were classed as vulnerably housed—for example, sofa surfing or living in bed and breakfast accommodation. The numbers have remained steady since then.
Pankhurst works closely with Gloucester City Council’s homeless team and has contacts throughout the county so he can secure a bed, even on a temporary basis, while he works out a more permanent solution.
“Sometimes it’s not what they want but it’s better than the streets. Very occasionally we have people who have burnt every single bridge so they have to take what is offered,” says Medcalf.
The pilot funding has now come to an end but the clinical commissioning group has agreed to fund the project until March this year, when the team will have to reapply.
Debbie Woodfine, primary care nurse for the homeless in Gloucester, says that hospital staff are often not aware of particular problems associated with homeless patients—around medication, for example.
“I would advise staff to prescribe a secondline drug if it was perhaps one that only needed to be taken in one dose, rather than a firstline drug that needed to be taken four times a day, for example,” she says.
The frustrations that Medcalf experienced are probably familiar to many doctors and nurses around the country. A 2015 report by Healthwatch England found that coordination between hospitals and housing services was poor, with local authorities being either unwilling or slow to respond to requests for assistance.1 And a recent audit of 23 emergency departments in areas with large homeless populations found that only 12 had a system for identifying and recording homeless patients.2
Medcalf is now the Royal College of Physician’s lead on health equity and is recommending a three tier level of support for homeless patients in hospitals: homeless patients at small community hospitals should be identified on admission and offered support and signposting; larger hospitals should have a Gloucestershire-style service with a specialist housing officer; and large urban hospitals should have a multidisciplinary team, identifying and helping homeless patients.
The college endorses the work of the charity Pathway, which has rolled out standards of care for homeless patients calling for coordinated healthcare in hospital, homeless ward rounds, and multiagency planning.
The charity has developed a model of enhanced care and has teams in five major central London hospitals as well as in Bradford, Manchester, Leeds, and Brighton.
Alex Bax, chief executive of the charity, says what unites homeless people are their “polymorbidities.”
“A man might be in hospital for a broken leg but the fact that he has uncontrolled diabetes, has trenchfoot, and is an alcoholic is not seen as the orthopaedic surgeon’s problem,” he says.
The service is led by a specialist general practitioner who works four sessions a week and bridges the gap between patients and the hospital doctor, as well as three full time nurses and three care coordinators, some of whom have been homeless themselves.
Pathway’s goals and way of working are similar to those of the Gloucestershire project—which he calls “Pathway-lite.” Posters are put up around the hospital and staff are urged to call if they suspect a patient is homeless.
The teams spend a lot of time cutting through the “horrendous bureaucracy around NHS care,” says Bax.
“There’s a lot of fear and nervousness among staff, and they just don’t know what to do a lot of the time,” he says.
Tackling social issues such as homelessness is a key part of any doctor’s job, says Jessica Allen, a researcher at the Institute of Health Equity at University College, London. A 2013 report, looking at the role of health professionals in combating health inequalities, included contributions from 19 medical royal colleges, who pledged to embed education on inequality into medical curriculums.3
“Poor housing and debt might drive a patient into the doctor’s surgery so they should have a role in trying to help patients with their housing or debt levels by referring them to other services,” she says.
As doctors become more involved in commissioning, says Allen, they need to think about where the money is spent and “the social value of their spend.”
The initial evaluation of the Gloucester project showed that the drop in average length of stay led to a saving of around £52 000 (€68 000; $74 000) over six months. But cost reductions were not the main driver for the project. For Medcalf the motivation was simple. “No patient should be discharged on to the streets,” she says.
Government statistics show there are 2744 people sleeping rough in England on any one night. The numbers have been rising since 2010, when there were 1768 rough sleepers4
The charity Crisis estimates that about 62% of single homeless people are not represented in official figures5
The average age of death for a homeless person is 476
Homeless people attend emergency departments five times more often than the housed population, are admitted 3.2 times more often, and stay three times longer6
Cite this as: BMJ 2016;352:i318
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.