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How to care for the homeless patient
Jason Phillips, a temporary resident, was put in at the end of a Friday evening surgery.
The T/R form had no home address. When Jason came in he explained that he was currently living on the street and
was running out
of his medication.
Dr Peter Moore discusses.
How should the registrar handle the situation?
If Jason is on regular medication he must have a GP somewhere. The registrar needs to ring the GP. I would be concerned if Jason was unsure of his last doctor. It is a Friday night and the other surgery may be closed, but Jason must have known he was running out and the medication is, ultimately, his responsibility.
We should avoid prescribing when we first see a homeless patient, especially for any potential drugs of addiction. Even after the patient is registered it is good practice not to prescribe for substance misuse problems unless it is a part of a package of care through the local specialist drug treatment centre.
Should Jason register with the practice?
One of the major problems for homeless people is the lack of medical care. If they have no GP their only access to health services is through A&E, which is inappropriate.
Most homeless centres have an arrangement with a local practice to provide a service and this can be done as a separate PMS project.
Although we need an address to register a patient it is possible to use an address such as The Bus Stop or register every homeless patient as living at the homeless centre even though they may be sleeping on the street.
Why should the practice care for
GP are often reluctant to take on the extra work involved with caring for those who are homeless. They do present a significant challenge, but we also know that their need for medical care is greater than the rest of the population's.
Half of all young homeless people have a drug or alcohol problem and a third of all homeless people have an alcohol problem.
Homeless people are four times more likely to die early than the general population. The highest mortality is in the 15- to 34-year- olds1.
It has also been shown that
homeless people with a dual diagnosis, both a psychiatric condition and substance misuse problem, experience significantly less clinical improvement with treatment than those without a dual diagnosis2.
As we are self-employed and run our own practices, it is difficult to take on substantial extra work without payment. As the care for homeless people is a Government priority the PCTs are being encouraged to offer some service to the homeless.
If a local practice can offer this care it would need to negotiate a fee. This is often done by setting up a separate PMS pilot.
Why are the problems of homeless people different from other patients'?
The problems start early in life. Many people who end up homeless were abused physically or sexually in childhood. They find it difficult to trust and to form stable relationships. This is followed by failure at school and no qualifications. Substance misuse then petty crime may follow. Many also suffer from psychiatric illness.
Once homeless there is a vicious circle. It is difficult to get a job without a regular address. To rent property people usually need a cash deposit even if it is paid for through the DSS. Without a job there is no money for a cash deposit.
If we add the problems of being unable to form relationships, substance or alcohol abuse, psychiatric illness, a criminal record and no qualifications it is not surprising that they cannot easily turn their life around.
By offering accommodation in a hostel and help through a drug centre the problems can be helped.
·It is possible to register a homeless person by using an address such as The Bus Stop
·Caring for the homeless is hard work requiring an investment from the PCT
·Half of all young homeless people have a drug or alcohol problem
·Treatment for substance misuse must only be as a part of a treatment programme working with the local specialist drug treatment centre
·Homeless people are four times more likely to die young than the rest of the population
1 Homeless people are more likely to die early. BMJ 2003; 327 (July 12)
2 G Gonzalez and R Rosenheck.
Outcomes and service use among homeless persons with a serious mental illness and substance misuse. Psychiatry Services 53 437-46 April 2002
Peter Moore is a GP in Paignton, Devon