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Why I chose... Working with homeless people

Dr Nigel Hewett explains why he chose to work with this vulnerable group of patients.

Name Dr Nigel Hewett

Title Medical director of Pathway homeless service

Location London

Background

I have worked with homeless patients for 22 years. I was a GP partner in a practice in suburban Leicester, and started off by doing a couple of half-day sessions a week trying to meet the needs of homeless people in the city centre. I then became involved in setting up a PMS pilot in 2000, resigning from mainstream practice and becoming a full-time salaried GP for homeless patients. This built up over a number of years to incorporate more staff and launch the Dawn Centre in Leicester.

The service went well and developed into an APMS project, gaining social enterprise status, that is now called Inclusion Healthcare. Around three years ago I was invited by UCLH to set up their service for homeless people.

I took the RCGP qualification in management of substance misuse, and also additional training in working with people with personality disorder and mental health problems. There is also now a faculty for homeless and inclusion health at the College of Medicine.

GPs are trained to deal with physical and mental healthcare and substance misuse, sometimes all in one consultation, and this is helpful when you’re seeing homeless people. This type of work is good for those looking for a challenge and interested in people on the margins of society. It’s also something you could do as an add-on to mainstream general practice.

What I do

I work as a salaried GP with a charity called Pathway, coordinating care for homeless people. I work in University College London Hospitals (UCLH). They were aware that they had large numbers of homeless patients attending, who in some cases had prolonged admissions. We set up a service involving myself, a full-time nurse and a care navigator with experience of homelessness. We go from bed to bed seeing patients, coordinating care and providing advocacy. As our recent BMJ paper shows, this has reduced bed days by 30% in the first year.1 We are now training other teams in London hospitals and elsewhere to provide a similar service.

Advantages

You don’t get see any `worried well’ in this job – the people you see have serious ill-health, so the potential benefits to them can be enormous. When they do turn their lives around, it’s rewarding. It’s a neglected area, so there are lots of opportunities for innovation and for developing services. Patients that you work with tend to have low expectations, so if you can offer them an excellent service it is plainly worthwhile.

Challenges

There are gaps between healthcare, social care and housing systems in the UK, with housing and social care boundaried by legally-driven processes, and this can be frustrating. Generally, the life expectancy of homeless people is not good – more like that of people in the developing world. The people you see may have a 30-year history of child abuse, neglect, institutionalisation and drug and alcohol misuse, and may find it very difficult to make changes, so you have to be able to deal with failure and keep on trying.

Reference

1 Hewett N, Halligan A, Boyce T. A general practitioner and nurse led approach to improving hospital care for homeless people. BMJ 2012;345:e5999.

Readers' comments (1)

  • Hi Dr Hewett,
    I work within Inclusion Health in Stoke on Trent and am currently extending my to Independent Nurse Prescriber. I am predominantly looking at concordance, equity, accountability in prescribing within this group. For example, prescribing a more costly macrolide, instead of recommended amoxicillin because the regime is less complicated, any tips?

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