Homeless Health Service

Updated 26 July 2017

The service is provided by BrisDoc Healthcare Services Limited and the lead GP acts as the registered manager. There is a concentration of homeless people around the city centre; a recent count by Bristol Council was that 76 people were classified as homeless. The inner city has a diverse community with areas of high deprivation and the highest proportions of black and minority ethnic (BME) residents in Bristol. Local health challenges in this locality include higher rates of drug, smoking and alcohol use compared to Bristol overall.

The location address is:

Homeless Health Service

Compass Centre

Jamaica Street

Bristol

BS2 8JP

The Homeless Health service is a flexible and responsive service designed to deliver positive outcomes for homeless or vulnerably housed people with complex needs. Services are based at The Compass Centre in Stokes Croft, Bristol, but staff offer outreach clinics in several locations around the city including The Wild Goose Cafe, One25, Logos House and Longhills.

Patients can be registered at the service but the intended purpose is to re-integrate people into mainstream primary care. The service works closely with the Broadmead Medical Centre who registers patients and has provision to meet the needs of patients with long term conditions.

The Compass Centre is run by St Mungo’s, a charitable trust, and provides access to the GP service, mental health support workers, a café run by homeless people, access to IT as well as shower facilities.

Patients can drop in for appointments with either a GP or a nurse Monday to Friday.

There are 4 GPs working within the service, there are the equivalent of 3.15 whole time equivalent nurses (including the lead nurse) and one whole time equivalent receptionist, and a practice manager who also works at the Broadmead Medical Centre.

BrisDoc has an APMS contract with NHS England for Homeless Health Service (with effect from 1 October 2016) for five years.

The intended benefits of Homeless Health Service are:

• To provide the best possible health care for patients.

• To promote better physical and mental health and well-being by offering a planned programme of health promotion and preventative care, and commissioned support to facilitate homeless people attend health and social care appointments, comply with management plans and achieve a good death in their place of choice. This is based on national and local guidelines and is aimed at those most at risk.

• To ensure that services are easily accessible, efficient and responsive to the needs of the patient.

• To maintain a pleasant, safe and efficient working environment for everyone working in the service.

• To include all members of the team in decision-making by encouraging teamwork and good communication.

• To support discharge from hospital and reduce emergency department attendances by providing responsive primary care and supporting services.

Homeless Health Service’s daily clinics and drop-in service offers:

• general health advice and treatment

• support and advice re: mental health problems

• safe injecting advice

• minor injury care

• leg ulcer care

• testing for sexually transmitted infections and pregnancy; all contraceptive methods available

• drugs/alcohol support and referral to other specialist services

• testing and counselling for blood borne viruses such as HIV/Hepatitis B & C

• opticians and podiatry services

• referrals and liaison with other health and homeless services.

  Number of patients attending:

• 1-3 times each quarter was 163

• 4-8 times per quarter was 96

• more than 8 times per quarter was 25

The BrisDoc headquarters is at Osprey Court, Hawkfield Way, Hawkfield Business Park, Whitchurch, Bristol, where the majority of the administration and human resources tasks are coordinated from.

Updated 26 July 2017

Letter from the Chief Inspector of General Practice

The service is provided by BrisDoc Healthcare Services Limited who have operated the Homeless Health Service since 1 October 2016. We carried out an announced comprehensive inspection at Homeless Health Service on 5 & 6 June 2017. Overall the service is rated as outstanding.

Our key findings across all the areas we inspected were as follows:

• The service implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients. For example, they held a user engagement day to review how patients viewed and accessed the service. This resulted in a plan to change the physical access and reception to the service.
• The service used innovative and proactive methods to improve patient outcomes, working with other local providers to share best service. For example, they worked closely with the local council homeless strategy and other providers to act on intelligence to seek out and offer outreach support to newly reported homeless people.
• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
• The service worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs. For example, they took services to where they were needed which included offering home visits to people in hostels and those whose ‘home’ was on the street.
• Feedback from patients from the Friends and Family Test was consistently positive.
• The service had good facilities and was well equipped to treat patients and meet their needs. The service showed determination and creativity to overcome obstacles to delivering care. The service took part in seasonal events and had worked with the Julian Trust to provide health care and support at the shelter for the Christmas week.
• The service actively reviewed complaints and how they are managed and responded to and any improvements needed as a result.
• The service had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.
• The service had strong and visible clinical and managerial leadership and governance arrangements.
• The service had clearly defined and embedded local and organisational systems to minimise risks to patient safety.
• Staff were aware of current evidence based guidance. GPs, nurses and locum GPs were skilled in caring for the patient group and had qualifications and experience in caring for patients with drug and alcohol addictions, challenging behaviours and supporting patients who were homeless or vulnerably housed.
• GPs working at the service took part in shared care prescribing for 70 patients who were part of the Supervised Methadone and Resettlement Team.
• There was a proactive approach to understanding the needs of this vulnerable patient group. Staff acted as advocates and delivered care in a way that meets patients’ needs and promoted equality. Patients told us they were treated with dignity and respect and were involved in their care and decisions about their treatment. Patients were respected and valued as individuals and were empowered as partners in their care. The staff had a culture of ‘unconditional positive regard’ for patients and no one was considered beyond help.
• Patients we spoke with said they found it easy to make an appointment with the service and said there was continuity of care, with drop in appointments available the same day. An average of 400 patients per month had used the service over the last twelve months.

We saw several areas of outstanding practice including:

Staff worked collaboratively with many other providers, both within the centre and externally, to ensure the vulnerable patient group was supported to receive coordinated care which met their needs. Service staff used opportunistic, innovative and efficient ways to deliver more joined-up care to patients. For example, the service worked with the University College London Hospitals’ TB (tuberculosis) ‘Find and Treat’ team, as part of a two-day initiative where 200 homeless people in Bristol were screened for tuberculosis.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Updated 26 July 2017

The service is rated as good for safe and effective and outstanding for caring, responsive and well led. This service is rated as outstanding for the care of people with long-term conditions.

• The service followed up on patients with long-term conditions discharged from hospital and ensured that their care reflected any additional social or health needs.

• Longer appointments and home visits were available when needed.

• The service worked in partnership with a local GP practice. The Homeless Health service had access to the practice systems and were able to register patients with long term conditions and make appointments for reviews directly.

Updated 26 July 2017

The service is rated as good for safe and effective and outstanding for caring, responsive and well led. This service is rated as outstanding for the care of families, children and young people.

• The service was available for the ‘homeless and vulnerably housed’ and did not provide services for families or young children.

• If any female patient became pregnant service staff linked them in and liaised closely with the midwife and maternity services.

• Access to contraception advice, medicines and support was also available to younger patients.

• The service worked in partnership with safeguarding agencies to protect the unborn baby.

Updated 26 July 2017

The service is rated as good for safe and effective and outstanding for caring, responsive and well led. This service is rated as outstanding for the care of older people.

• The service had a small number of older patients. For example, of the 741 patients seen by the service, only 29 were over 59 years old. The service offered proactive, personalised care to meet the needs of the older patients in its population.

• The service was responsive to the needs of older patients, and offered home visits as well as a walk in appointment service to see a GP and/or nurse every day.

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.

• The service identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.

Updated 26 July 2017

The service is rated as good for safe and effective and outstanding for caring, responsive and well led. This service is rated as outstanding for the care of working age people (including those recently retired and students).

• The age profile of patients at the service was mainly of those of working age

• The service offered 15 minute appointments as standard but appointments took as long as was needed.

• The service did not currently offer extended hours as patient demand did not require this.

Updated 26 July 2017

The service is rated as good for safe and effective and outstanding for caring, responsive and well led. This service is rated as outstanding for the care of people experiencing poor mental health (including people with dementia).

• The service regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health. There was a weekly meeting to share information across agencies. In addition information was shared at the outreach clinics as it arose. We observed that One25 had a meeting before and after each session to share intelligence and that the Wild Goose Cafe had mental health workers there who would share and update on individuals if needed.

• Some of the street drinkers attending the clinic had been subject to or witnessed severe trauma in the past but because of their alcohol use were not able to access the full range of psychological services. This service was able to support them whilst still drinking which gave patients the opportunity to change drinking behaviours and improve psychosocial wellbeing.

• The mental health support team were sited within the same building. The clinical team liaised as required with them and also met every month with the team and psychiatrist to discuss and review the current caseloads, priorities and update the patient plan.

• Safeguards were in place to make sure high risk medicines were identified and regularly monitored. The service held a list of all patients on ‘depot’ medicines, which included the date when it was last given and next one due. The list was closely monitored by the staff and demonstrated the team was proactive in engaging with patients on this medicine to ensure their safety.

• The service had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations; this was actively promoted by service staff.

• The service had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

• Shared premises enabled face to face discussions to take place and for responsive support to be available when patients were in crisis.

• Staff had received training on how to care for patients with mental health needs and dementia. Staff recognised that many patients lived with cognitive impairment from acquired brain injuries and took time to ensure treatment or advice was clearly understood.

• The service worked collaboratively with local pharmacy so patients could attend daily to have their medicines dispensed.

Updated 26 July 2017

The service is rated as good for safe and effective and outstanding for caring, responsive and well led. This service is rated as outstanding

• The majority of patients at the service were classed as ‘vulnerable’ either due to their social circumstances (housing situation), health or both. For example, homeless patients, travellers, patients with mental health issues and those with learning difficulties. The aim was to refer patients to a mainstream GP; the service currently only retained 11 patients permanently registered with them.

• The dedicated team acted as advocates for patients and worked in partnership with other involved services to ensure that vulnerable patients took priority and were monitored and sign-posted appropriately to receive the best care and support available.

• The service was situated within a homeless community service hub which made it easier to signpost directly and avoided unnecessary delays with care plans and duplication of work. This enabled all patients to receive the most effective care pathway for their circumstances.

• All staff working at the service had experience in the treatment of drug and alcohol addiction, and had worked with people with mental illness.

• Staff interviewed knew how to recognise signs of abuse in young patients and adults whose circumstances may make them vulnerable. They were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.

• Homeless patients could access a GP from the practice without an appointment at the walk in clinic five times a week. They could also be seen by appointment at different times of the day if they preferred. The service was responsive and saw all patients needing urgent assessment and treatment within minutes of arriving.

• Staff from the service worked in the outreach clinics which targeted specifically more vulnerable and hard to reach groups.