National enhanced service - enhanced care of the homeless
2 May 2003 (updated February 2004)
Introduction
1. All practices are expected to provide essential and those additional services they are contracted to provide to all their patients. This enhanced service specification outlines the more specialised services to be provided. The specification of this service is designed to cover the enhanced aspects of clinical care of the patient, all of which are beyond the scope of essential services. No part of the specification by commission, omission or implication defines or redefines essential or additional services.
2. This NES is directed at practices serving a critical mass of patients.
Background
3. Homelessness is commonly used to describe a wide range of circumstances where people have no secure home. Homelessness is defined in legislation for the purpose of determining entitlement to help from local authorities. Certain groups are defined by law as being in priority need of housing. These include pregnant women, families with children, all 16 and 17 year olds, those who have physical and mental health problems, people who have experienced domestic or racial violence and people who are vulnerable following a stay in institutions.
4. However, in order to target health services on the most difficult to engage homeless people, it is necessary to consider a wider range of clients. Many of the most chaotic and vulnerable may not be in contact with housing authorities. Groups to consider are:
(i) rough sleepers
(ii) hostel and night shelter residents
(iii) bed- and- breakfast residents
(iv) squatters
(v) people staying temporarily with friends and relatives.
5. Of those who approach Local Authorities, 184,290 households were found to be homeless in England in 2001.(see reference 1) Shelter estimates that this represents over 440,000 people. This figure, however, does not reveal the full picture.
6. Official statistics indicate that homelessness is currently on the rise. For example, there was a 3.5 per cent increase in the number of statutory homeless households in priority need between 2001 and 2002.
7. Although the nature and extent of the health problems that face homeless people will vary according to their particular experience of homelessness (for example rough sleepers are often more likely to suffer from musculo-skeletal problems), research has shown that across the board, people who are homeless face an increased risk of mental illness, physical illness, of contracting infectious disease and drink and drug abuse. (see reference 2)
Aims
8. To ensure that:
(i) homeless people have equal access to appropriate levels of service from practices designed to ensure that their health needs are effectively tackled
(ii) GPs are provided with the knowledge, training and resources to enable them to deal effectively with homeless people’s health needs
(iii) GP services are empowered to tackle the health needs of homeless people holistically by working with relevant services (eg housing & social services) to integrate homeless people into local communities.
Service outline
9. This national enhanced service will fund:
(i) the development and production of an up-to-date register. Practices should be able to produce an up-to-date register of patients who are homeless or organisations to whom they provide services
(ii) liaison with local statutory services and homelessness agencies and where appropriate the development of joint protocols, e.g. with the local authority's Homeless Persons Unit (HPU) as well as links with local A&E departments where appropriate
(iii) awareness of and participation in local homelessness strategies and forums
(iv) the proactive promotion of health services to the local homelessness community ensuring that they are aware of the services available to them
(v) flexible registration procedures allowing for permanent registration to anyone who wants it
(vi) flexible appointment systems including walk in surgeries and longer appointment times for people with multiple needs
(vii) dispensing arrangements with local pharmacies that allow for the administration of single or daily doses of prescription drugs
(viii) the provision of training to appropriate practice staff ensuring an understanding of and sensitivity towards the particular problems faced by homeless people. As well as the issues associated with health and homelessness, training should provide staff with a general understanding of the range of problems faced by homeless people, eg access to appropriate housing and problems with benefits
(ix) provision for appropriate and regular screening assessments based on current research in relation to the health needs and problems of homeless people
(x) provision of outreach services
(xi) the use of relevant guidelines on the prescription of drugs in particular if medication has street value or potential toxicity
(xii) provision of a health promotion and harm minimisation programme
(xiii) appropriate referral to counselling and CPN services if applicable
(xiv) specialist assessment of the physical and mental health of homeless people when registering. Key elements should include:
(b) a high index of suspicion of substance use and, where appropriate, initial assessment and/or referral
(c)assessment of psychological wellbeing and referral if necessary.
(xv) review. All practices involved in the scheme should conduct an annual review which could include:
(a) feedback from homeless patients
(b) an audit of physical and mental health problems experiences by the homeless
(c) the length and number of consultations for each homeless patient
(d) referrals to and use of other services both within and outside the practice by homeless patients.
Accreditation
10. Those doctors who have previously provided services similar to the proposed enhanced service and who satisfy at appraisal and revalidation that they have such continuing medical experience, training and competence as is necessary to enable them to contract for the enhanced service shall be deemed professionally qualified to do so.
Costs
11. In 2003/04 each practice contracted to provide this service will receive an annual retainer of £1,000 plus an annual payment per patient (paid quarterly in arrears) of £100. These prices will be uprated by 3.225 per cent in 2004/05 and again in 2005/06.
- Shelter. Housing and homelessness in England: The facts, 2002
- Pleace & Quilgars. Health and homelessness in London. 1996:34 Audit Commission. Changing Habits - The commissioning and management of community drug treatment services for adults. 2002:10 London Drug Policy Forum. Housing drug users - Balancing needs and risks. 1999: 5 Randall G. Drug services for homeless people - A good practice guide. Homelessness Directorate, 2002: 15 Randall G. Drug services for homeless people - A good practice guide. Homelessness Directorate, 2002: 15 Ballintyne, S. Unsafe streets - Street homelessness and crime. IPPR, 1999: 16 Audit Commission. Changing habits - The commissioning and management of community drug treatment services for adults. 200: 10 London Drug Policy Forum. Housing drug users - Balancing needs and risks. 199: 5 Randall G. Drug services for homeless people - A good practice guide. Homelessness Directorate. 2002: 15