Last week I met with someone who, having just completed a Masters in Epidemiology, is keen to work in the health field. Over a hot chocolate I outlined my perception of the current big issues relating to substance misuse, our most vulnerable populations and the policies and structures we have in place to address these issues.
Unsurprisingly, given current circumstances, it was not a wholly positive picture. Progress in some areas, for example TB, are matched by record drug related deaths and, for the first time in many years, worrying drug prevalence data around the use of opiates and crack cocaine. Despite my naturally cheery character (honestly) I could have ended up quite depressed if it wasn’t for the fact that I was talking to someone brimming with enthusiasm and energy to see what they could contribute to tackling some of our most glaring health inequalities. And certainly, enthusiasm and optimism, coupled with knowledge and understanding, are essential requirements when seeking to navigate the current landscape where financial resources are increasingly hard to find, and structures can often seem to hinder rather than help.
One of the subjects we discussed was the problems faced when people are seeking to access various health services. Many of us who are, allegedly, relatively organised, with some knowledge of the health system and considerable resources in terms of access to the internet, telephones or a secure postal address, have stories about the problems we or loved ones have experienced when trying to get treatment and services, being passed from clinic to clinic, with different consultants and specialists dropping in and out. Tests, scans and medication are often determined within a silo, continuity of care is hard to ensure. Appointments are cancelled at short notice, administration is often poor (this applies as much to the private sector as the NHS, the only difference often seeming to be more comfortable seats and a water cooler in the waiting rooms of the former). How much harder for those with less personal resources and social capital?
Healthwatch, the independent champion for those who use health and social care services, produced a report last December which highlighted the additional problems faced by those who are experiencing homelessness. These included being unable to register with a General Practitioner because they didn’t have proof of address. Accessing any service was difficult, this could be again be linked to identification issues, but also ringing up to make appointments or being contactable could prove impossible. Homeless people often felt that their situation was poorly understood and that there is a reluctance to invest time and resources in their needs. They experienced significant problems in getting the range of help needed and often felt that they were penalised for struggling to comply with health advice or treatment regimes.
While a depressing tale, it is, in many ways, hardly surprising. But given the community as well as the individual consequences this situation is clearly of concern. Also, if we have a genuine commitment to addressing health inequalities, we surely need to focus on a group whose health out comes and life expectancy are so poor, with homeless men in England dying on average at 47, for women its even worse at 43.
Some great work has been undertaken. The Kings Fund are undertaking a major piece of work looking at access to health services for rough sleepers and the impact of ill health in preventing people getting off the streets, this is due to report in the autumn. At a practical level Pathway have developed models of care for the homeless and rough sleepers. Over the last decade they have brought together a network of professionals who are involved in the health care of excluded groups, including vulnerable migrants and sex workers. Their work combines compassion with the highest professional standards. I have met some of those who have benefited from the work of Pathway and the results have been truly transformative. In 11 hospitals they have established homeless healthcare teams. These help those in need deal with the whole range of problems they are coping with, be it physical ailments, mental health issues, substance misuse etc. It’s a system that seems to work. So, what are the magic ingredients?
Of course it is essential to have highly trained specialist doctors and nurses, the Pathway teams include a specialist GP, links to community services, someone who can help access accommodation and the immediate basics of fresh clothes and shoes can be provided, they have also established Pathway Care Navigators, someone with lived experience who can not only relate to the individual but guide them through the maze of officialdom and service structures.
The idea of a care navigator has utility way beyond dealing with the well-recognised marginalised groups. Parts of the NHS are exploring how it may not only help patients but also reduce demand on GPs. Let’s hope that the great work of Pathway, Find and Treat and other services leads to wholesale improvements that help people experiencing homelessness live significantly longer, healthier and happier lives. It may well be the case that this is an example of approaches developed to help the most marginalised benefits the mainstream. Many of us when we experience ill health will have other problems and issues in tow. When we are ill our ability to cope with even the most benign bureaucracy is reduced. We are not one dimensional, we cannot be reduced to a single pathology. We could all benefit from a good navigator.