Richard Lowrie
Homeless people slip through the cracks in preventative healthcare, despite having multiple and complex needs and high rates of unscheduled care use. A traditional pathway of incremental escalation of treatment based on planned appointments in busy health centres doesn’t work.
People who are homeless are the most marginalised group of people you’ll ever come across. They are alienated, with multiple complex physical, mental health and addictions problems and they don’t access healthcare in a way we would consider normal. Reasons for this include previous negative experiences and perceptions, fear of stigmatisation, previous traumatic experiences and personality disorders. Many are vulnerable, with poor health literacy, claustrophobia, agoraphobia, anxiety – and find it really difficult to wait in a queue in a waiting room. As a result, homeless people often don’t get prescribed the medicines that they need for their long-term conditions, or attend their GP enough times to receive a diagnosis in the first place
People who are homeless don’t routinely present themselves to seek help until their health problems have become overwhelming. And then they present to acute emergency services. At the hospital, the precipitating issue will be fixed but they may then leave without the multitude of their other health problems being addressed and nothing will have been put in place for follow up, sometimes because tracking the patient is difficult if there is no fixed abode or mobile phone number.
We have therefore introduced an outreach pharmacy service to go to where patients are. What we are trying to do is engage and anticipate their conditions deteriorating to the point of needing to go to emergency services.
Being able to prescribe independently means that we can treat patients on the spot. We go to where our patients are: on the street or at soup kitchens or homeless hostels, places where they trust the staff: they are not going to be judged or worry that the police will be called for whatever reason. And we try to be there when people are being discharged from a hospital. It’s about striking while the iron is hot and being available when people are in the right zone to accept help.
It’s also about not trying to address all the person’s problems all at once, that sort of thing tends to scare people away – the evangelical approach that says, ‘I’m going to weave some magic and you’ll be better after that’. Instead, it is about developing trusting therapeutic relationships through serial encounters. What we try to provide for them is a bit of attention and support. It takes a while but sometimes that relationship, with the constant support we have alongside us from the Simon Community street work team, can start them on the road to their having their own accommodation.
We do prescribe differently. Where someone presenting to their GP with COPD might be started on salbutamol with the advice to come back in a month, we may have to turn the guideline on its head because we cannot assume the patient will return, and the sooner we establish control of the patient’s breathing, the more likely the patient will return. Our patient will probably have presented very late in the day, so salbutamol may not be strong enough to do much for their symptoms and, if the medicine is too mild for them, they’ll lose faith in us being able to help. This approach is undertaken carefully, fully aware of the risk/benefit ratio, and in conjunction with strong advocates like GPs and consultant respiratory physicians.
When we write a prescription, we usually have to take steps to ensure that our patient follows through. We work in partnership with city centre community pharmacists. We phone them up, explain that someone’s coming down with a prescription, then follow people up the next week. We’re wary of the additional risks of giving people too many medicines because of the chance of the patient losing them or taking too many.
My hope from speaking at the Celtic Conference is to spread the message that pharmacists have a lot to offer this very high-risk patient group. We can deliver pharmaceutical care through independent prescribing in a way that is really well received by what is a growing population, not just in Glasgow and Edinburgh where we’ve been funded to work by Healthcare Improvement Scotland, but in all UK cities.
We are evaluating this work robustly. At the moment we have the results of qualitative work with patients and stakeholders that will be published in March or April. Quantitative evaluation will follow and eventually I hope we can have a randomised controlled trial of our complex intervention. The evidence base for our approach has to be robust enough so that healthcare decision-makers can say ‘yes, this is worth doing and it is cost-effective’. And anyone who wants to join us developing this evidence is very welcome to contact Kate or me.
Richard Lowrie, Lead Pharmacist in the Homeless Health Service for Glasgow.
Richard Lowrie’s colleague Kate Stock will be leading a session on the work of the Homelessness pharmacy team at the Celtic Conference for Pharmacy in Scotland, Wales and Northern Ireland, being held in Edinburgh on Tuesday 26 March. Registration is free for healthcare professionals at www.pharman.co.uk/celtic-conference. Lauren Gibson, Advanced Clinical & Research Pharmacist Homeless Healthcare was also involved in the project.