The GP practice sharing data to transform care for homeless people

Steve Benson* is happy. He’s just come out of a a 10-minute consultation with a GP he has never met, yet she was able to instantly pinpoint the help he needed. Thanks to the data sharing system being pioneered at BrisDoc, Bristol’s homeless health service, he didn’t have to go over his story yet again.

For this 45-year-old, whose home is a tiny tent in Bristol’s city centre, this successful session is a big deal. Benson lost his house, job and children when the traumas of his army past sent him careering into alcohol and drug addiction. He needs urgent help for a range of complex conditions but, like many rough sleepers, rehashing his story could be enough to trigger further self-destruction.

“You get so sick of retelling your story. But this time the GP could see my notes, and she used the entire time with me to chat about my mental state,” says Benson. “I really found that helpful. Now we’re talking about counselling.”

Benson and the other homeless patients at the Compass Centre, near Bristol’s main bus station, are seeing the benefits of an ambitious data-sharing scheme that was introduced in October 2016 and is being developed at BrisDoc. The aim of the scheme is to pool all available information from medical, psychiatric, social agencies and prisons to enable doctors to work effectively with patients.

Bristol has the second highest number of rough sleepers in the UK, after Westminster. The number of people sleeping rough in Bristol is 74 according to the most recent count. Nationally, the number of rough sleepers has increased by 51% over the past two years, from 2,744 to 4,134.

If BrisDoc gets the data sharing right with this complex group of patients, the GPs involved believe the model could be applied across the NHS. “The pioneering work being done by the BrisDoc homeless health service shows the benefits that integrated care can bring,” says Dr Shaun O’Hanlon, chief medical officer at Emis Health.

Building the existing data platform has been made possible by combining information from two main systems – the Emis data-sharing platform used by 106 GP practices in Bristol (covering about one million patients) and Connecting Care, a local electronic patient record allowing health and social care professionals in Bristol, South Gloucestershire and North Somerset to access outline NHS patient information.

Before October, that information would have taken hours to collect on the phone, faxing and rifling through papers. Now GPs can see whether a person has been admitted to hospital (and to which ward), how many times they have been to A&E, and whether there are any missed or imminent outpatient appointments.

Dr Mike Taylor, lead GP, is passionate about developing service-specific auto-populating templates for each patient depending on which part of the system they end up in.“In this siloed world, this is something of a miracle,” he says. “The vision is to have a complete, up-to-date picture of our patients. Up to now we have been dealing with an old jigsaw, with pieces missing and no clear image on the front to help us put together the pieces.”

A marker of a civilised society is how we deal with those down on their luck

Mike Taylor

Taylor gives the example of police or paramedics being called to a street dweller wandering drunk through rush hour traffic. A glance at the data platform can indicate whether this person is known to mental health teams, which would lead to a referral there and avoid unnecessary sectioning or a night in police cells.

“These are not feckless joy riders,” he insists, although he admits he’s always on the alert for a physical attack. “Every time you go deep with a homeless person you find out that they have been abused senseless and cannot cope with their pain. A marker of a civilised society is how we deal with those who are down on their luck.”

Adult and child protection data is the most recent addition to the platform. Now Taylor is pressing for more complete information on mental health, dental treatment, prison and housing history, as well as end-of-life plans for each patient. He also wants ambulance, police and triage teams to have access.

For David Ingerslev, rough sleeping service manager for St Mungo’s, the electronic platform has been transformative. “Before its introduction, I have seen support workers spend a day trying to trace a client, only to find out that they are in hospital,” he says. “Now that link can be made in five minutes.”

*Not his real name

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The GP practice sharing data to transform care for homeless people

Homeless people with brain injuries are still invisible to the NHS

Homelessness is on the rise and has been for the past five years, with government statistics suggesting a 55% increase in the number of people homeless in 2015. Despite this, people living on the streets still remain largely invisible to regular NHS services, leading to a big problem in health inequalities.

Brain injury presents a particular challenge. Homeless people are five times more likely to be hospitalised due to head injury, compared to the general population and US research suggests that roughly half of all homeless people may have had a traumatic brain injury. . These figures are higher still if we include dementia and substance-related brain injury, such as alcohol-related brain damage. Yet we still do not have properly-funded support for homeless people who have sustained such traumas.

The most common type of brain injury among homeless people is traumatic brain injury, often caused by a blow to the head during an incident such as an assault or traffic accident. Other forms include strokes, brain cancers, dementias, and damage caused by drug or alcohol use.

Symptoms can include changes in personality, speech problems or walking difficulties, as well as issues with concentration and memory. Behaviour changes may also occur, such as becoming more aggressive.

Sheffield’s head injury and homelessness research group recently carried out research to explore the interaction between homelessness and brain injury. It was led by someone who had suffered a brain injury and been homeless

The research focused on the experience of homeless people themselves. Where previously they may have reproached themselves for being clumsy, lacking motivation, being aggressive, or an alcoholic or a “junkie waste of space”, the programme helped them to stop blaming themselves for what had happened to them.

The research has also resulted in a film, made with support from Deaf Pictures, telling the story of Michael, one of the participants in the research. His story is painful, but not unusual. Yet the interaction between brain injury and homelessness is rarely mentioned in homeless research and policy, meaning people like Michael often become invisible to society and to services.

[embedded content]

Deaf Pictures’ short film on homelessness and brain injury.

Homeless people too often get bounced between drug and alcohol teams, re-housing schemes, accident and emergency units, and mental health services. Even if they are fortunate enough to have a sympathetic GP, a homeless person is still likely to be expected to attend a brain injury clinic at a scheduled time. Many won’t attend, and simply end up being discharged.

If services are to meet the needs of homeless people, then they must be built with homeless people and, most importantly, must be provided where they are, rather than in clinics far removed from the everyday life of the person struggling with the effects of a brain injury.

Services can and should be developed and funded to bring brain injury assessments and follow-on support to those in need. In doing so, we can expect better longer-term outcomes for such individuals and find ways together to reduce the invisible cycle of homelessness and brain injury.

Stephen Weatherhead and Rebecca Forrester are clinical psychologists

Some names have been changed.

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Homeless people with brain injuries are still invisible to the NHS

Homeless individuals discharged from hospital had nowhere to go – right up until now

Thomas Stanney was cycling back to his short-term accommodation when a man opened his vehicle door and Stanney crashed straight into it. The collision sent him tumbling onto the street and fractured his pelvis.

Stanney, who also has diabetes, was in hospital for 6 weeks. Faced with getting nowhere to go after discharged, a group from St Mungo’s Broadway, a homelessness charity and housing association, came to see him and secured a location in the hospital discharge network (HDN) in Hackney, in which sufferers can convalesce soon after a remain in hospital.

“I would have been in difficulty [with no the network] simply because I’d made myself homeless. [The council] threw me out of the accommodation they’d put me in temporarily whilst I was in hospital. The only location I had to go was the streets.”

He adds: “I could just about stroll again when I left hospital. I was still sore. When I got down on the floor, I struggled to get back up once more. It would have been pretty challenging to survive on the streets.”

The hospital discharge network was set up two many years in the past with over £3.6m of funding from the Division of Health in an energy to minimize hospital readmission prices and A&ampE attendance amongst homeless folks in London. There are 4 centres in central London offering accommodation and on-website medical providers. A team of nurses and psychologists function alongside wellness and housing support staff to aid the particular person move on as their remedy comes to a close. The profile of clientele demonstrates several wants, with many lengthy phrase and acute circumstances like diabetes, persistent liver illness, hepatitis, HIV and more. Soon after a keep in the HDN, consumers are helped to move on to supported housing or independent accommodation.

The Division of Overall health estimated that the expense of hospital therapy for homeless people is at least £85m a 12 months (pdf), meaning expenses of far more than £2,a hundred in contrast to £525 per particular person amongst the basic population (pdf). Portion of the purpose for the expense differential is that homeless people predominantly bypass main care companies, and go straight to A&ampE when they hit crisis level. Andrew Casey, director of well being at St Mungo’s, says that use of emergency solutions by homeless folks is several occasions that of the standard population. “Some homeless folks use A&ampE more than primary care, specially if they’re moving all around and do not remain in a single location. It is challenging for them to get into a GP practice … and they really don’t engage really effortlessly or readily with well being providers.” he says.

Thomas Stanney (proper) stayed in the hospital discharge network right after he fractured his pelvis in a traffic accident. Photograph: St Mungo’s Broadway

Homelessness is a overall health situation, according to Casey. Homeless Link’s 2014 Overall health Needs Audit (pdf) is a device aimed at assisting commissioners and practitioners gather data on the wellness requirements of homeless men and women, and making certain providers are in location to meet nearby demand. Its survey identified 73% of homeless men and women reported a bodily wellness dilemma and of people who did, 41% reported their situation as extended phrase, in contrast with 28% of the common population. Meanwhile, 45% of individuals surveyed had a psychological well being diagnosis in contrast to 25% amongst the basic population.

Casey says: “Physical, psychological and alcohol problems usually stem from traumatic experiences in earlier life. That can lead to homelessness. Then if somebody’s sleeping on the street, you can see how their health can decline really rapidly specially if their requirements are not tended to.”

I get looked following so properly that I’ve minimize down [my alcohol intake] to three or four cans a day.

Brian Stone

Brian Stone*, 57, from Hackney, had been living on the streets for two years when he was supplied a location in a St Mungo’s hostel in Hackney. He has angina, suffers from nervousness and depression, and utilised to drink 28 cans of cider and beer a day – a habit he designed on the streets. When he collapsed in his area, he was taken to hospital and diagnosed with cirrhosis – scarring of the liver induced by prolonged-term damage. This was not the very first time he had been admitted to hospital for drinking-connected problems. He was accepted into the hospital discharge network exactly where, with the aid of the on-internet site nurse, and going to psychiatrist and GP, he has minimize back on his consuming and obtained help for his psychological health problems.

He says: “Since I’ve been in the unit, I’ve had so a lot support. I get looked soon after so properly that I’ve lower down [my alcohol intake] to 3 or 4 cans a day. It is been hard but I’ve acquired the staff here to support me.”

He has far more of a deal with on his mental well being troubles which used to avoid him from going out alone. “The nervousness stopped me from leaving my space. That has altered now. I attend artwork, cooking and pottery lessons.”

And, it’s not just Stone that has observed a distinction. Catherine Lake*, a locum well being help worker for St Mungo’s says: “Brian is visibly a good deal happier. Physically, he seems a whole lot healthier. It is the spirit that is the massive modify along with the physical. He’s capable to talk far more … and take change in his stride.”

So far, the initiative appears to be doing work. In the three months from April to June this 12 months, occupancy for the hospital discharge network in Hackney – a single of the centres in central London – was one hundred%. From nine clients admitted to the services in this time period, there have been a complete of twelve admissions to hospital (not including A&ampE) before their stay in the HDN. Right after staying in the centre, this reduced to two.

Connected: How one London borough aims to improve homeless people’s health

Even though in the HDN, the 9 clientele attended 30 main care appointments with GPs, dentists, opticians, podiatry and substance use solutions. This was a 97% attendance price – only 1 appointment was missed. In the case of 1 personal consumer, in the three months prior to staying in the HDN they attended A&ampE on 30 occasions. For the duration of their keep, this decreased to three A&ampE attendances.

As Stone says: “If it wasn’t for a area like this, who understands what would have took place. When you are on the streets and it’s pouring with rain or snow, you are down and out, you tend to believe issues … When you come to a warm bed and personnel, issues alter.”

* Some names have been altered

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Homeless individuals discharged from hospital had nowhere to go – right up until now

A day in the lifestyle of ... a wellness visitor for homeless families

Tracy Bromley helps households living in hostels and refuges, as effectively as the Gypsy and Traveller communities, achieve access to wellness, housing and social care providers.

I like to be in the office by 8am, or could start off the day functioning from house. This flexibility implies I can log on to the network to accessibility clinical data without having obtaining to travel throughout rush hour – it truly saves time.

As a expert well being visitor for homeless families, I cover a wide geographical area, but carry a smaller sized caseload than generic overall health visitors. This indicates my team and I can offer you an enhanced services to the vulnerable households we appear soon after. It is my task to assess the well being needs of homeless families and help them access overall health providers and other mainstream providers.

There is no normal day at work with my role: no two days are ever the identical. The families that I work with are transient in nature, and I travel to their short-term accommodation wherever they are primarily based. This may include households who are residing in hostels or bed and breakfast accommodation, people of no fixed abode and the Gypsy and Traveller community. I also operate with families who are living in refuge accommodation possessing fled domestic abuse, and would really like to build a vulnerable families wellness-going to team.

The bed and breakfast hotels are spread across the town, and it is normal for me to check out a family members who are residing in one area. Private amenities are typically shared, and it is commonplace for there not to be any cooking facilities. The mothers and fathers that I meet truly worry about having to feed their family on takeaway food and, for those who are already on a reduced revenue, the value adds to their concern.

When I knock on the door, households are actually pleased to meet someone with whom they can share their worries and who is sympathetic to their crisis situation. In the course of the day I could liaise with housing officers, as households actually benefit from getting assistance to get an update on their application for housing.

The factor of my function that I discover most rewarding is gaining the trust and self confidence of my consumers and being ready to advocate on their behalf. The households that I operate with could quite effortlessly be ignored as they do not often have a voice. It is essential that I increase awareness of the influence that homelessness has on the well being of families, so my day might include attending meetings with other agencies. I am operating to enhance communication between wellness and social care.

In the course of the day my automobile gets my workplace and en route I will cease and make calls, perhaps to a midwife, children’s social care or to our neighborhood meals bank to acquire a parcel for a family members in need to have. Lunch is generally in my auto this provides me room to catch up.

My eclectic nursing background has led me to my present function, and my passion is working with varied groups. I may finish the day by visiting an unauthorised traveller encampment that has pitched up on a nearby website. We know that the wellness of Gypsies and Travellers in the United kingdom is much poorer than that of the common population. The families on web site are pleased to see a well being visitor and ask for assistance with receiving their children’s “needles” (the Traveller phrase for immunisations) completed.

Due to the fact of the transient nature of their accommodation, homeless households are less probably to be registered with a GP. Part of my work is to facilitate obtaining this sorted out as quickly as attainable, which in flip assists all of us in direction of the aim of improving the well being outcomes for homeless families.

When I am not working I adore to travel. I notably like cities and I am working my way by means of my must-see wish checklist around the world.

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A day in the lifestyle of ... a wellness visitor for homeless families