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How we serve socially excluded groups

Dr Simon Tickle explains how his practice has set up services dedicated to marginalized groups such as sex workers, asylum seekers and the homeless.

Our practice was established in 2001 and serves all those who have difficulty accessing primary care – the homeless, Travellers, sex-workers and the increasing numbers of asylum seekers and refugees at the time.

The idea came from Dr Cath Hewitt, who had been running a small clinic at the soup kitchen and we started from scratch in 2001 as a PMS+ practice in Northampton town centre.

We now have over 5,000 patients and, although the demographics of our practice population have changed over time, we have shown that primary care is the best place to manage and co-ordinate the care for socially-excluded patients who often have very complex needs.

What needs do these patients have?

Sex workers, homeless people and those with unstable accommodation – such as those on bail or in hostels/temporary housing – often present with major drug, alcohol and mental health problems.

These patients have complex needs. Many have personality disorders and often have come into conflict with staff in standard GP practices. We have tried to develop ways of engaging, managing and ‘containing' them.

To tackle this, we have developed a ‘violent patient contract' for the county and are assessing how best to develop this for the future.

The number of Latvians, Poles and Romanians has increased in recent years and we rely heavily on interpreting services.

How are you funded?

From the start, the PCT has been supportive and had the funds to support us, with additional resources came from a variety of central and local government t sources.

This may change. Our current funding developed piece-meal over the last nine years and needs to be rationalised over the next 12 months, and renegotiated as PMS+ has ceased to exist.

At present we have mental health specialist nurses and a clinical support worker funded through PMS+, but we also have an enhanced capitation payment for all new registrations over 3,500.

We also get local enhanced service payments for the 280 patients for whom we provide structured drug treatment for opiate dependency from the Drug and Alcohol Action team (DAAT) through the Adult Pooled Treatment Budget. The DAAT also funds a Drug Worker for our Sex Workers.

We need to move to separate enhanced service contracts for our various socially-excluded and complex patient groups and develop appropriate outcome measures which can be monitored through the IT system.

I need to persuade our commissioners that the premium we ask them to pay for our services to these vulnerable groups is justified and can be included in mainstream funding.

An additional attraction of developing a variety of enhanced services for complex patients is that other practices will also be eligible to apply for them and so, we hope, will be backed by our local PBC consortium, Nene Commissioning.

What have been your main challenges?

Our patients eat time. Interpreting can doubles consultation times and often our patients have never been given a chance to talk about their problems before.

Engaging in a therapeutic relationship with these patients takes time, with explanations, arguments and conflicts due to distrust of authority figures common. We also need time for multi-disciplinary team discussions.

I work in a consultant role supporting other clinical staff in their decision-making and we all get stressed in this environment at times and need time to talk over issues. If we don't have time for patients and each other, explosions start to occur.

What about the future?

Our funding is not secure. We are in competition with others and our patients are those who, by definition, are often neglected. But our patients are expensive to society in numbers of ways which we may be able to influence, and they have a strong moral argument for better care, with the prevention of ongoing health and social costs in subsequent generations.

Primary care is the best place to manage and co-ordinate the care needed for our socially excluded patients. Advocacy and the building up of a network of supportive relationships within the practice from reception staff onwards are key to managing all these groups successfully. It is no accident that these are core values of traditional general practice.

Dr Simon Tickle, is a GP partner at Maple Access Partnership LLP in Northampton,

Dr Simon Tickle