Attributes of CSSs:
General practices that provide health care to the general population, including people who are homeless. CSSs receive additional NHS funding for their work with patients who are homeless.
Both CSSs have a long-standing philosophy to deliver health care to single people who are homeless. This aspect of their work has evolved over many years, with some staff having considerable experience of this work.
Stand-alone medical centres. Fully equipped to deliver primary health care.
SP1 – designated nurses and support staff exclusively for patients who are homeless, receptionists/administrators, and sessional workers (mental health, substance misuse and social workers). GPs provide care both to patients who are homeless and to the general population.
SP2 – nurses and GPs provide care both to patients who are homeless and to the general population; receptionists/administrators; and sessional workers (therapists/counsellors).
Local homelessness context:
Located in cities with large populations of single people who are homeless. Many participants in SP1 were sleeping rough. According to staff at both CSSs, there has been an increase in the number of people homeless in recent years. Opportunities for begging and availability of drugs has attracted people from elsewhere.
According to staff, there has been an increase in complexity of health and substance misuse problems among people who are homeless and in their use of drug ‘spice’.a The latter has had significant effects on users’ mental health and led to poor engagement with services.
Several hostels/temporary accommodation projects/day centres for single people who are homeless in locality of CSSs. Some are also accommodated in local bed-and-breakfast hotels.
Local networks of statutory and voluntary sector agencies involved in the provision of temporary accommodation, day centre services and street outreach to people who are homeless.
Many charitable services support people sleeping rough in the area of SP1. According to SP1 staff, this has attracted people to the area and encouraged street homelessness.
Other specialist primary health care services in other parts of city for single people who are homeless.
Policy/funding/resource influences:
Cuts to housing, health and social support budgets, lack of affordable housing, and changes to welfare benefits and sanctions have contributed to people becoming and remaining homeless.
Restructuring/closure of local hostels have resulted in some people who are homeless being dispersed outside city centre and away from support networks. Harder for CSS staff to engage with such patients.
SP1 (information from staff):
Multiagency work has been impeded by short-term funding and separate commissioning arrangements for different services. More resources needed to enable CSS staff to serve local people who are homeless but not accessing the CSS.
Contractual arrangements for the provision of GP services prevent CSS staff from treating people in hostels, day centres and on the streets who are not registered at the practice.
Great difficulties accessing mental health services. Mental health practitioner at CSS weekly, but works only with patients with severe mental health problems.
Great deal of strategic work with NHS England, local health care commissioners and local authority. Contribute to plans/provide information/advise/attend meetings. Tackling homelessness seen as a priority by commissioners and the local authority.
SP2 (information from staff):
Insufficient resources has meant lack of capacity to undertake work with other agencies, run additional clinics in hostels and day centres, conduct street outreach, attend multiagency meetings. Difficulties recruiting GP because of funding arrangements also affects performance.
Poor integration and access to mental health services, particularly secondary care for patients who misuse substances.
Developmental work at the CSS impeded/delayed by insufficient resources/support from CCG.
Lack of co-ordination and joint working between local authority and health services. For example, health services not always invited to local authority strategic/multidisciplinary meetings concerning people sleeping rough or temporary housing for people who are homeless.
Some strategic work with CCG and local authority: provide information/advise/attend meetings. Building links with public health. | Operational mechanisms:
Number of registered patients relatively large – SP1 more than 10,000; SP2 more than 5000.
Some CSS staff knowledgeable about the problems and needs of people who are homeless and of local services. Regular staff meetings/training around patient care.
Open Monday to Friday. Flexible approach offering drop-in sessions and booked appointments. Some drop-in clinics each week at SP1 specifically for patients who are homeless. Daily drop-in clinics at SP2 for all patients (restricted number of slots each day).
Frequent street outreach by SP1 staff to engage with people sleeping rough and encourage them to access health care. No street outreach by SP2 staff.
SP1 participants and staff describe CSS as a welcoming and accessible environment: staff greet patients by name, and are friendly and helpful.
All aspects of primary health care undertaken by GPs and nurses – health assessments, treatment for acute illnesses, management of long-term illnesses, health promotion, immunisations and screening.
Comprehensive health assessments for new patients at SP1, including social/housing histories.
Person-centred approach to care – most case study participants described staff as caring, listening, giving patients enough time, and involving patients in decisions about their care and treatment.
Holistic approach to care – at SP1, assessments of, and help given for, non-medical needs. Support/social workers part of team that assists with housing, welfare, social problems.
According to SP2 staff, information about non-health needs is not routinely collected. Welfare advice worker runs sessions at CSS (but not part of team).
Protocols in place and acted on to address challenging behaviour of patients in the CSS.
Conducted audits of problems and needs of patients who are homeless (both CSSs).
Patients encouraged/assisted to register with mainstream general practices once settled in housing and no longer homeless if they move out of local area.
Integration mechanisms:
At SP1, substance misuse services available at CSS, with shared care arrangements for patients receiving OST; mental health worker at site weekly. Patient care meetings attended by CSS staff and specialist workers.
At SP2, patients referred/signposted to mental health and substance misuse services. Fairly close working with substance misuse services.
SP1 involved in hospital inpatient/discharge work for people who are homeless, with regular hospital visits. SP2 has communication with hospitals regarding particular patients.
Dental treatment clinics specifically for people who are homeless available at CSSs/in locality.
Close working with street outreach teams by staff at both CSSs. SP1 staff conduct some joint outreach sessions with the street teams. The latter accompany patients to the CSS.
Close working with some hostels and day centres. Regular clinics/sessions by SP1 at several sites, and at a few sites by SP2.
Attendance by SP1 staff at multidisciplinary case management meetings with local agencies, including those concerning safeguarding, high-risk or complex cases, and people sleeping rough. SP2 staff attend such meetings occasionally.
SP2 – regular meetings with local GPs and with those working in deprived area.
SP1 – close working with housing, adult social care and probation services regarding particular patients.
SP2 – close working with housing services regarding particular patients | Participants’ characteristics:
Most participants White British and in hostels/other temporary accommodation during the study. Mental health and substance misuse problems common, including misuse of Class A drugs and injecting drugs (similar percentages as participants).
Health screening (primary outcome):
Very high scores for screening of mental health, alcohol use and smoking. Low score for TB screening. Total Primary Outcome Score slightly lower than that of Dedicated Centres and Usual Care GPs.
Management of SHCs:
Nearly all cases of alcohol and drug problems, and most cases of chronic respiratory problems, mentioned by case study participants were documented in medical records.
Several cases of depression mentioned by case study participants were not documented in medical records.
Treatment plan initiated for nearly all SHCs identified in medical records.
Relatively high levels of continuity of care achieved for all SHCs (slightly lower scores than for Dedicated Centres). Continuity of care for drug problems fairly low for SP2.
Self-rated health and status and well-being:
Low levels of physical and psychological functioning at baseline (all models). Statistically significant improvement in scores at 8 months for Specialist GPs.
Smoking and nutrition:
Most participants were smokers, and many described poor nutrition. Slight improvements by 8 months in eating habits. As with Dedicated Centres, just over one-third received help with nutrition from CSS staff.
Oral health and dental treatment:
Poor oral health, dental pain and dental phobia common (all models). Many in need of dental treatment; rates of registration with dentist and dental attendance low.
Slight increase in dental registration rates by 8 months. Lowest rate of dental attendance during the study, compared with other models. Just over one-third believed that dental health worsened during study.
Use of services and costs:
More contacts with GPs than Mobile Team and Usual Care GP participants, but not as many as Dedicated Centre participants. Not as many contacts with nurses as Mobile Team participants. Overall service use costs similar to those of Mobile Team participants, lower than those of Dedicated Centre participants and considerably higher than those of Usual Care GP participants.
Number of contacts with GPs and nurses at CSS higher for SP1 than for SP2. Number of A&E attendances and use of ambulances higher for SP2 than for SP1.
Satisfaction with CSS:
SP1 participants described finding it easy to see doctor or nurse; several SP2 participants reported difficulties. High satisfaction ratings by SP1 participants for (1) overall experience of CSS and (2) Quality of Care provided. Most reported confidence/trust in doctor or nurse. Ratings slightly lower foraSP2 participants. Overall ratings for this model higher than those of the general population and UC participants. |
