Do GP commissioners know the scale of health problems amongst the homeless?
The Government has prioritised homeless care, writes Steve Shrubb, but have GP commissioners done the same?
Homeless people have some of the most complex physical and mental health problems that many professionals will ever encounter. We have to see this challenge as a spur to do better. In the NHS Confederation's Mental Health Network latest briefing with homeless charity St Mungo's, the people who run mental health services recognise that they need to improve they way they support and care for homeless people.
With the economic outlook remaining bleak, we also have to be honest with ourselves that this challenge is going to get bigger. About 70 per cent of homeless people have a mental health problem and the latest figures from Autumn 2011 suggest there are 2,200 rough sleepers every night in England - a 23 per cent increase from 2010. Meanwhile, thousands more spend their nights in hostels and other types of emergency accommodation.
Mental health services believe this is just the tip of the iceberg. we probably have 2,200 rough sleepers in London alone. There are also a lot of young people moving from couch to couch, staying on friends' floors. It is not going to take much to provoke a crisis and for these people to end up on the streets.
One study suggests that homeless people are 40 times more likely not to be registered with a GP than the general population. Access is key although not in itself sufficient. Many homeless people have a history of abusive relationships and are therefore often acutely aware of actual, or perceived, slights or abuses of power. Gaining their trust and developing a relationship with them is much more difficult. Meeting this challenge requires appropriate staff training and making sure services are provided in the right way, where homeless people are. And this, you will be unsurprised to hear, is the hard part.
Many places, however, are showing that it is possible.
The Cambridge Access Surgery is a general practice whose 400 registered patients are all homeless, or at risk of becoming homeless. Approximately 70 per cent of patients are drug users, 50 per cent misuse alcohol and 40 per cent have a mental illness. They also experience high degree of morbidity for a range of physical health problems. In addition to providing routine primary care, through both drop-in sessions and scheduled appointments, the surgery manages substitute prescribing for around 60 drug users. It also provides mental health support through a psychiatrist and a community psychiatric nurse, who specialises in the treatment of severe alcohol dependence. It also works closely with the mental health outreach team, provided by third sector organisation CRI (Crime Reduction Initiative).
The key to this surgery's success is that it addresses all the issues in one place and works effectively with other agencies involved in the care and support of homeless people.
There are other examples set out in the briefing, but the common traits are pretty clear. They include: mental health services are best provided closer to where homeless people are - for example, in drop-in clinics or hostels; services need to be better at staying in contact with homeless people once they use them - for example, by having a named contact in charge of homelessness health; the NHS needs to work more effectively with other, often specialist services such as alcohol dependency clinics.
We are keen to see these services copied more around the country. We all have to up our game.
The boards and leadership of mental health providers need to be sure that staff have the requisite training and that services properly take account of the needs of homeless people. They also need to be sure that their services are working effectively with others.
New Clinical Commissioning Groups and Health and Wellbeing Boards also need to ask themselves some important questions about how good their data on homelessness is, how well needs are being addressed in the Joint Strategic Needs Assessment (JSNA), what the opportunities are to improve support for the homeless and what existing services are in place.
There is no doubt this is going to be challenging. But it is not good enough, for example, to tell a homeless person who may be intoxicated on drink or drugs to simply go away and come back when they are clean. We know that many won't, yet, we also know that services are available that can help. We have to rise to the challenge for one of the most vulnerable groups we will support and care for.
Steve Shrubb is the director for the NHS Confederation's Mental Health Network.