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CQC Essentials: Looking after homeless patients in general practice

When the CQC inspects GP practices, it will look at the quality of care for people whose circumstances may make them vulnerable; this includes people who are homeless.

This article relates to the CQC key questions: Is your practice effective? and Is your practice responsive to people's needs?

People who are homeless experience some of the worst health outcomes in society. Homelessness is associated with multiple and complex health needs and premature death. Homeless people attend A&E five times as often as the housed population, and are admitted to hospital more often, for much longer periods.

The issues

In 2014 Homeless Link reported that 90% of the homeless people they surveyed were registered with a GP. However many responded that they were not receiving the help they needed for their health problems, and 7% had been refused access to a GP or dentist in the previous 12 months. In some cases these refusals were due to having missed a previous appointment or because of behaviour. Others reported that they were refused access if they did not have identification or proof of address.

The Health and Social Care Act 2012 introduced statutory duties on the NHS to 'have regard to the need to reduce inequalities' in access to and outcomes achieved by services.

Many practices request multiple forms of identification and proof of address when registering new patients. This can be useful for them to ensure identity and contact details. The GMS contracts Regulations (2004) state that practices may only refuse an application to go on their list if they have reasonable grounds for doing so which do not relate to the applicant’s race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition.

Expected standards of care

CQC expects practices to register people who are homeless, people with no fixed abode, or those legitimately unable to provide documentation living within their catchment area who wish to register with them. Homeless patients are entitled to register with a GP using a temporary address which may be a friend's address or a day centre.

The practice may also use the practice address to register them. Practices should try to ensure they have a way of contacting the patient if they need to (for example with test results). Some areas will have special services for homeless patients and practices may refer homeless patients into those services in line with local arrangements where it is in the best interests and with the agreement of the patient.

The Faculty for Homeless and Inclusion Health

The Faculty for Homeless and Inclusion Health is a multi-disciplinary body focused on improving the healthcare of homeless and other multiply-excluded people. The faculty has produced standards for commissioners and service providers to follow when planning, commissioning and providing health care for homeless people and other multiply-excluded groups. This includes some specific examples of good practice:

  • Pro-active management of selected patients with high needs
  • Hospital in-reach ward rounds/visits for homeless patients where necessary
  • Regular outreach clinics in local hostels and drop-in centres
  • Drop-in clinics with presenting problem addressed first, with extended services (e.g. screening) offered
  • Training to help medical staff understand homeless people’s needs for example ensuring receptionists are ‘gate openers’ for excluded groups rather than ‘gatekeepers’

Practices may also find this document useful:

Example of outstanding practice: Inclusion Healthcare Social Enterprise

This multi-agency practice based in the city centre of Leicester provides high quality care for homeless persons and other vulnerable groups. The team comprises general practitioners, consultant and practice nurses, specialist drug and alcohol workers and a health support worker, providing holistic high quality care.

Inclusion Healthcare has achieved:

  1. Health Service Journal awards 2014 highly commended for compassionate care
  2. Accreditation as an RCGP training practice in substance misuse and alcohol
  3. Outstanding rating following CQC inspection

Innovative qualities of this practice that make it particularly outstanding are:

Safe: The practice has developed its own significant events reporting process that is timely and responsive. They have weekly meetings to discuss the care of complex patients and any concerns raised about them from other agencies. Patients who had taken an overdose were discussed in depth within the team and other agencies, and any learning from this event was shared.

Effective: In response to above average DNA (did not attend) rates for hospital referrals, the practice has introduced a system by which a health care assistant acts as an advocate for patients  and reminds them of upcoming appointments. The practice offers access to specialist drug and alcohol workers, and has weekly meetings where referrals to third sector services can also be arranged for patients where appropriate.

Caring: The practice contributes to funeral costs and memorials for patients who were homeless and maintain a memorial wall on their premises. Information in the waiting room, on TV displays and on the practice website signposts patients to other organisations and support groups of benefit; the computer system also flags up if a patient is a carer so that they can be given written information on services and support available to them. Patients rate the practice higher than others for almost all aspects of care as consistently and strongly positive. The practice regularly engages with external services such as community health care, hostels, prisons and young offenders institutions.

Responsive: The practice has a lead practitioner for end of life care and patients with long term conditions to ensure high quality care for these groups. The premises have been adapted to be easily accessible to those with mobility needs; there is also a separate discrete waiting area for patients who wished for privacy while waiting. The practice has a very flexible appointment service, offering longer appointments where needed and regular same day drop-in clinics. If a patient misses an appointment, the practice contacts third party agencies to ensure that they are safe.

Well-led: The practice has a clear leadership structure with named members of staff in lead roles such as for infection control and safeguarding. It holds regular governance meetings and actively discusses QOF data, producing action plans to meet or maintain targets. The practice holds annual staff away days to build team relationships. Staff report an open and honest culture where concerns can be raised and discussed in a neutral and constructive manner.

Feedback following CQC inspection rating

…from staff:

CEO Dr Anna Hiley: 'We are delighted. This is a team achievement and one which we should all be very proud of. It is a significant recognition of the work that our team do every day to support our vulnerable service users.'

Senior practice nurse, Tracy Pollard: 'We aim to raise awareness of long-term conditions with our patients and develop their understanding of how improving their health is just as important when homeless.Providing holistic care in a small time scale can be difficult but goes a long way in improving their health and well-being, that someone does care.'

…from multi-disciplinary partners in Leicester:

'I can't tell you how proud and grateful I am for all you have achieved. You are really flying the flag for homeless health care.'

'Huge congratulations to you all, absolutely fantastic report and feedback'

'Well deserved recognition to an amazing team of staff - Well done to each and every one of you'

'That’s great news but its only credit where’s its due. Very happy for your service and proud to work alongside you all too'

'Well done, affirms what we all know locally'

'Brilliant, but I’m not surprised!'

  • Professor Nigel Sparrow is senior national GP advisor and responsible officer at the CQC

More CQC resources

Picture: iStock

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