Dedicated Centres

The Dedicated Centre model was represented by two CSSs [Dedicated Centre (DC) 1 and DC2]. Both had existed for many years and had developed substantially over time. They were located in large cities that had a substantial problem of homelessness, and were relatively close to several hostels and day centres for people who are homeless. Their catchment area was citywide. Both had a practice manager, GPs, practice nurses, and reception and administrative staff. Most staff had considerable experience of working with people who were homeless. DC1 had a full-time primary mental health nurse, whereas the community mental health team worked part time at DC2. Substance misuse workers held sessions most days at the sites, but were not employed by the CSS. Both sites had additional specialist workers, but these cannot be identified to maintain anonymity.

Both sites were part of an NHS trust and operated in similar ways. DC1 held a contract as an APMS; DC2 also held a special contract. They were open Monday to Friday, and were covered by a GP out-of-hours service. Both offered permanent GP registration. In contrast to many mainstream general practices, the caseloads of the CSSs were relatively small.

DC2 mainly focused on single people who were homeless, whereas DC1 also provided care to asylum seekers and refugees. Neither site provided registration to the general population, and once patients were rehoused and settled, they were assisted to register with mainstream general practices services. The sites offered booked appointments at the practice and a same-day drop-in service. The duration of appointments tended to be longer than at mainstream general practices, for example DC2 allocated 20-minute appointments, instead of the customary 10 minutes.

Dedicated Centres provided GMS, including management of acute and chronic illnesses, smoking cessation, immunisations and vaccines, treatment for infestations and referral to secondary health care services. They also provided mental health care and counselling, and access to community alcohol detoxification programmes and drug treatment, including opioid substitution treatment (OST). CSS staff conducted street outreach at least monthly to engage with rough sleepers and encourage them to access services. Staff at DC1 also visited drop-in centres regularly to encourage registration. At both sites, nurses or health support workers visited day centres and hostels at intervals to deliver influenza vaccination programmes and health promotion. Staff accompanied patients to hospital appointments if necessary, and helped them access housing and welfare benefits services. Daily staff meetings were held at both sites to discuss patients, and regular staff training took place.

Mobile Teams

The Mobile Team model was represented by two CSSs [Mobile Team (MT) 1 and MT2], which had been in operation for several years. They were based in urban areas with a substantial number of people who were homeless, and several hostels and day centres for this population. Both teams were funded by the NHS to run clinics and deliver health care in these settings. They worked Monday to Friday.

The Mobile Teams mainly comprised specialist nurse practitioners with considerable experience of working with people who were homeless, and some were non-medical prescribers. They received some administrative support, and input from mental health practitioners. They worked closely with local general practices, and some joint work in hostels was undertaken by MT1. They provided health care to people who were homeless, to asylum seekers and refugees, and to people with no recourse to public funds. MT1 also offered health care to people who were housed, but who attended homelessness sector day centres for support.

Neither team provided GP registration, and patients were encouraged by the CSS nurses to register with local general practices. This meant that patients could receive health care from both a GP and the Mobile Team. Those registered with a GP received an out-of-hours service through the general practice. Caseloads were reviewed periodically by the Mobile Teams, and cases were closed once care was complete or if contact had been lost. Their caseloads tended to be small (see Table 6).

Services provided by the Mobile Teams differed from those provided by other models. Much of their work concerned assessing the health needs of patients, and linking them to local services, including general practices and drug or alcohol agencies. Occasionally, nurses accompanied a patient to appointments if there was an urgent need, or if the person was not engaging with services. They were less involved in acute disease management other than ensuring that patients were seen by a GP or at a hospital if necessary. They undertook health promotion, longer-term care for conditions such as leg ulcers, and routine blood tests.

The Mobile Teams held drop-in nursing clinics in hostels or day centres on set days and at fixed times. The frequency of clinics ranged from 1 to 5 days a week, and each lasted 2–4 hours. The offices where the Mobile Teams were based did not have facilities for patient care. The spaces available to see patients in hostels and day centres ranged from well-equipped clinical rooms to rooms used by other services, or simply a screened area in a drop-in centre or hostel sitting room. Access to a consultation with a nurse was primarily through a list held by hostel or day centre staff, or by the nurse actively seeking out individuals during a clinic. The Mobile Teams conducted frequent street outreach to engage with people sleeping rough.

Specialist GPs

The Specialist GP model was represented by two CSSs [Specialist GP (SP) 1 and SP2]. Both were in urban areas with high rates of homelessness and had been operating for several years. They were mainstream general practices delivering health care to the housed population, as well as additional or enhanced services to people who were homeless. Hence, the total number of patients registered at these practices was considerably higher than that of the Dedicated Centres and Mobile Teams, but the number of patients who were homeless was comparable. One site had more than 10,000 registered patients, of whom an estimated 850 were homeless. The other had between 5000 and 10,000 patients, of whom around 300 were homeless.

Unlike other models, there were noticeable differences between the two CSSs in the Specialist GP model. Both had GPs; practice nurses; HCAs; and reception, administrative and information technology (IT) staff. Two GPs at each site had a special interest in homelessness, although they worked with all patients. At SP1, some practice nurses worked primarily with patients who were homeless, and non-clinical team members provided case management to those with complex health and social care needs. At SP2, nursing care was delivered by practice nurses who worked with both patients who were housed and those who were homeless.

Both CSSs were funded by the NHS, and held additional contracts for their work with patients who were homeless. They were open Monday to Friday, and were covered by a GP out-of-hours service. Besides booked appointments, SP1 offered drop-in sessions for people who were homeless three times a week. At SP2, drop-in sessions were provided daily for all patients. The CSSs provided general primary health care, management of acute and chronic conditions, wound care, and immunisations and vaccines. Both had input from sessional mental health workers. At SP1, drug and alcohol workers also held clinics on a sessional basis, and provided community alcohol detoxification and drug treatment, including OST and needle exchange. At SP2, drug and alcohol treatment was not available on the premises; patients were referred to local substance misuse services.

Both sites held clinics in hostels and day centres for people who were homeless, although the frequency of these varied. SP1 held several nursing clinics each week at these services, and visited other sites to engage with service users who were not accessing health care. Staff also undertook street outreach with other agencies. At SP2, clinics were held twice weekly by GPs at homelessness services (see Table 6).

Usual Care GPs

The Usual Care GP model was represented by four CSSs [Usual Care GP (UC) 1, UC2, UC3 and UC4]. They were mainstream general practices delivering primary health care to the general population, which, by default, included people who were homeless. Unlike Specialist GPs, they did not provide special services or have dedicated staff for patients who were homeless. Three sites had caseloads of more than 15,000 patients, the fourth had slightly fewer. The proportion of patients who were homeless ranged from 0.04% to 5.4%. All had a PMS or APMS contract, and all except UC1 received additional funding to work with patients who were homeless (UC1 received funding for work with patients with substance misuse problems).

All were open Monday to Friday, and three also opened on Saturdays (see Table 6). When closed, a GP out-of-hours service provided cover. All provided permanent GP registration, and pre-booked and same-day appointments. They employed a range of staff associated with the running of a general practice, including GPs; practice nurses; HCAs; and reception, administrative and IT staff. Unlike the other models, they either employed a non-dispensing pharmacist or had a pharmacist providing sessional services. The pharmacists dealt with prescription queries, undertook medication reviews with patients and reviewed prescribing practices. The use of clinical pharmacists in general practice was introduced as a pilot scheme in 2015, and became part of the funding framework for general practices in 2019. Hence, they were not in operation when Dedicated Centres and Specialist GPs were recruited.

All four CSSs provided general primary health care, including management of acute and chronic diseases, smoking cessation services and routine blood tests. Sessional workers provided specialist services at the CSSs, although this varied between sites. Drug and alcohol services, including OST, were provided at UC1 and UC3 by GPs through shared care with local drug services. At UC2, a similar long-standing arrangement had ended because of funding cuts, and the drug service took over all care. UC1 and UC4 employed a mental health nurse; UC3 had input from mental health practitioners on a sessional basis. Only UC2 offered no on-site specialist mental health care.

All except UC1 held registers of patients who were homeless. UC2 and UC3 used a computer-based ‘homeless template’, which prompted clinicians to ask about specific issues when a patient attended an appointment, such as alcohol consumption. No sites held clinics in hostels or day centres for people who were homeless, but UC3 visited local hostels annually to encourage residents to attend a homeless health check. UC2 was close to a hostel and in regular communication with hostel staff.

Summary

This chapter summarises the various ways in which the four Health Service Models delivered health care to people who were homeless. There were marked differences in the sizes of the practices, the ways in which they operated, the services provided and their patient populations. These differences will be considered when evaluating the effectiveness of the models in delivering health care to people who are homeless. The next chapter describes the patients of these models who agreed to be case study participants.