Posted by: GPs To Be1 September 2016
I can’t stop thinking about the practice I visited last week. On the surface, it’s just another GP surgery, with the usual huddle of patients clustered at the door waiting for it to open.
But something’s very different here. If you look closer, you’ll see the cups of tea that are offered as they walk in. The donated Pret A Manger wraps laid out in the waiting room. The drawer stuffed full of clean underwear and socks. And when they’re called through, the tiny but tenacious figure of Dr Mary Hickey that welcomes them in, clearly revered by her patients.
The patients value their surgery more than any I’ve ever met
Dr Hickey is a nun. Her partner, Dr O’Reilly, is a Jesuit priest. And look closer still, and you’ll see the patients chatting amicably over cups of tea are a little different too.
The surgery cares for people living in hotels and hostels, squats and refuges, as well as on the street. The bulk of their patients are alcoholics and drug addicts. Dr Hickey opened the doors nearly 30 years ago, after she came back from Africa to find that some of the patients that needed her most were her own doorstep. She’s never looked back.
The motivation of the surgery is easy to understand: to provide general practice to the homeless population that’s just as good as everyone else expects. But exactly how they do this is a different story.
Take Barry, our first patient. Dr O’Reilly explained that he’d met Barry in the early hours of the morning on the streets. The practice has a Street Doctor Programme, where staff go on night walks through the local streets, talking to rough sleepers. They found Barry cowering in a corner on one of the richest streets in Europe. Now, in the light of day in a warm consulting room, they agreed to restart his methadone. It was only after Barry had left, that I realised he was just 35. He looked almost twice that.
'Did you know that the average age of death of a homeless person in London is just 42? Barry’s actually doing well - an intravenous drug user like him would actually be likely to die before their mid-30s,' Dr O’Reilly explained. 'But get him on a methadone programme and into a hostel, and his mortality rate can be brought right back down to less than 1%. Guess what the NNT (number needed to treat) is for that? 11.'
I didn’t know what to say.
Then there was Imran, a diabetic schizophrenic. He’d been ferried back and forth to A&E several times after collapsing from hypoglycaemia. The last time this happened, paramedics had plucked him out of a precarious construction site. But Imran wouldn’t accept any help finding accommodation. The nurse explained that he was haunted by the death of his father, who’d had been found dead at home alone after injecting drugs. All she could do was give him some Fortisips for emergencies.
'We can’t give him many though,' she explained, 'The Fortisips have street value. At the end of the day, he has to take some responsibility.'
I asked her how she found working there.
'I love it. Here, all the clinics are walk-in. I can spend as much time as I need with my patients. We don’t depend on QOF for payments, so I can focus on them. And they mostly wait without a grumble, because they know how much we care.'
Next up was a 31-year-old homeless woman, whose scarlet-streaked Mohican skimmed the door frame as she limped in. We all held our breath, trying to block out the miasmic stench from her infected leg ulcers. She was still injecting into her groin. Her partner had died from his own maggot-infested leg ulcers only a few months before. I stared at the raw, red muscle visible at their base. But hospital was out of the question. We could only encourage her to come back regularly. Who knew if she would.
The smell that lingered in the air for the rest of the day will definitely stay with me. But most of all, I’ll never forget the last patient: a middle-aged, well-dressed, articulate lady, who was registering for the first time. With fleeting glances at the floor, she told us she’d been living on the streets for a couple of months. She was an actress, and the work had simply dried up. I’d never have guessed she was homeless. The nurse told me that there are so many like her on the streets under the radar - in the past, even a junior doctor and consultant paediatrician had sat in that very same chair.
Dr O’Reilly terms homelessness a ‘disease of relationships’: what happens when no one in the world will give you a bed for the night. It’s a final common pathway of so many conditions. I was struck by how this silent disease can infect and destroy so many lives, with no immunity. I don’t think I’ll look at a homeless person on the street in quite the same way again.
That day, I caught a glimpse of underground medicine that I didn’t know much about. An incredibly kind team, serving society’s most vulnerable patients, and all living between the palaces of Buckingham and Westminster.
The patients value their surgery more than any I’ve ever met. And the staff go above and beyond their roles to give them what they need. Yet no-one's in any doubt about who holds the ultimate responsibility when they walk out of the door.
I must admit, I was surprised at how happy the staff and patients were. And I didn’t expect to say this, but I think there are lessons to be learnt here for us all.
Dr Nishma Manek is a GP trainee in London. You can follow her on Twitter @nishmanek
Dr Paul O'Reilly is one of this year's local heroes in the Pulse Power 50. Find out more here.