‘Homeless general practice: the most fun you can have in medicine without GMC attention’

Dr Paul O’Reilly shares a day in his life working as a GP for the homeless population in central London

My senior partner says that homeless general practice is the most fun you can have in medicine without coming to the attention of the GMC. By the bottom of this page I hope to persuade you that she’s right.

8:55am and counting
My day begins shamefully close to 9am as I somnolently park up my bike. One of the nicest things about working with homeless people is that they are generally no better at getting out of bed than we are. Even so, there will often be a collection of enthusiastic folk in the front garden on our patio chairs, breakfasting off the endless teas (average three sugars) and sandwiches provided by our reception staff. Our practice manager says: ‘We may not be able to make ‘em better, but we can at least make ‘em welcome.’

As usual on a Wednesday morning, there are people I have met on our Tuesday night street-outreach shift with St Mungo’s and invited to the surgery. Occasionally, some new people will be sleeping outside the surgery to be first in line. Today it is a young couple we found bedded down outside Queensway station at midnight who wanted treatment for their drug dependence. Since then, they have showered at the day centre and put on their best remaining clothes; the lady has even put on some make up. I am reminded how hard our people work just to get here. They approach a doctor as anxiously as a GP approaches a bank manager. Having visited mine recently, I know the feeling and we do everything we can to put them at their ease.

9:30am
Morning clinic is two doctors and two ANPs seeing people as fast as we can. One doctor and ANP team manages the general clinic; the other works the drug and alcohol service.

On the general side, it is not much different from mainstream practice; people come and go who are ill, believe themselves to be ill, or wish to avoid becoming ill. The major difference is the range of disease. Medically speaking, homelessness is a disease of relationships – it is what happens when nobody in the world will give you a bed for the night. Its major medical causes are the diseases which destroy the human capacity for relationality – drugs, alcohol, chronic severe mental illness and personality disorder.

Our patients carry an immense burden of morbidity. Much of that is psychiatric: 56% of our population have some kind of mental health diagnosis; and 21% have a diagnosed major psychosis. That is reflected in the mortality. Average age at death in the general homeless population is 46. Within our practice that rises to 54 – a number of which I am never sure whether to be proud or ashamed. For untreated street homeless injecting drug users, it is 34.

The temptation might be to despair, but for some reason that never happens. I suppose it is because our patients have so much wrong with them that there is always at least something you can do for them. And there is something intensely rewarding about that. After all, we all joined the profession in some sense ‘to make it better’. These are people for whom there is a lot to make better.

2pm
In the afternoon, I go to an outreach clinic at Connections St Martin’s, just off Trafalgar Square. We commit a lot of resources to outreach – to hostels, homeless day centres and to the street. A general practice for homeless people needs to be at least as concerned for those who do not come to us, as those who do. Homelessness medicine is always a team game, and this is a clinic of all the talents, bringing together: the Connections staff, homeless health nurses (CLCH), the Turning Point specialist drug service and ourselves. A young woman recently started back on methadone who needs a good 10 minutes to recover herself after breaking down in tears of relief at finally getting back onto her script.

The highs and lows come quick and fast in homelessness medicine. Today, we are lucky to get one of the highs. I see a young man who has long had a painful lump on the front of both legs, just below the kneecap. Apparently, a doctor once told him that he had Osgood-Schlatter’s disease, but was too busy to explain. Impressed by the eponym, the chap naturally assumed that this must be some dreadful form of cancer which would, at best, require his legs to be amputated. A brief explanation and he too needed a few moments to recover from his relief. Even amongst the sickest people, reassurance is our best medicine.

5:30pm–ish.
Back at the surgery, there is a visit needed to a nearby hostel. A gentleman well known to us for his bipolar mood disorder and alcohol dependence is ‘not quite himself’ and won’t let anyone into his room. Hostel workers are minor saints who care for even the most difficult and challenging people at immense personal and emotional cost. I have learned to trust their instincts. It transpires that the chap had fallen in his room, taken to his bed, and been unable to move for over 24 hours, vehemently refusing to let anyone in. But a familiar voice makes it easier; he permits me to examine his shortened and externally rotated leg, and ultimately admits that he probably does have a broken hip and will need to go in.

6:30pm
I return again to the surgery and the usual evening of clinical administration – test results, clinical correspondence, emails and electronic ‘tasks’ that we have been sent to perform in our capacity as community house officer to hospitals, community services and sundry others. Our people are capable of generating a truly extraordinary amount of paperwork!

Who-knows-what-o’clock
And sometime, later tonight, I will go home, filled with the reward of having seen patients getting better because of what we are able to do for them and feeling the camaraderie of a team I love like family. I shall reflect once again that this is the best job I have ever done. And I shall resolve once again to keep on doing it until I am stopped either by act of God or the GMC.

Dr Paul O’Reilly is a GP partner in London who works for homeless people