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A primary care service for socially excluded patients

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VOL: 103, ISSUE: 24, PAGE NO: 30-31

Judith Lydon, BSc, RN, RHV; Scott Harrison, BSc, MA, PGCert, RN, RHV;

Judith Lydon is community matron for vulnerable adults, Warrington Primary Care Trust; Scott Harrison is public health nursing supervisor, Fraser Health Authority, British Columbia, Canada.

This article describes the development of a community matron-led primary care service designed to meet the needs of people who are socially excluded, such as asylum applicants and the homeless.

Abstract Lydon, J., Harrison, S. (2007) A primary care service for people who are socially This article describes the development of a community matron-led primary care service designed to meet the needs of people who are socially excluded, such as asylum applicants and the homeless. It also contains recommendations for primary care staff to improve services for, and access to, these hard-to-reach groups. IntroductionHomelessness and asylum are prime focuses of UK social policy within the broader context of social exclusion (Social Exclusion Unit, 1998), as a result of real and identifiable need - in particular the increasing numbers of homeless people and asylum applicants and the consequences of this for service provision - and of broader trends and issues. These include the increasing part the media play in communicating and mediating social issues: images of rough sleepers in doorways, homeless people begging for money and asylum-seekers awaiting relocation in ‘holding centres’ are potent symbols used to both support and challenge government policies. As a result, we use the term ‘asylum applicant’ rather than ‘asylum seeker’ to overcome the negative images presented in the media (Quickfall, 2004). This, in turn, has led to a greater focus on the multifaceted nature of both the causes and symptoms of homelessness and the implications of this in relation to service delivery (Roche, 2004). Biomedical theories that often guide health services do not explain the health impact of social issues (Young, 2006), which often have negative health consequences. A clear example of this can be found in homelessness, which has significant consequences for both individuals and the wider community (Wright and Tompkins, 2006). Homeless people and asylum applicants experience poorer levels of general physical and mental health than the general population and there is a substantial evidence of multiple morbidity. Despite this, these groups often have problems obtaining suitable healthcare (Wright and Tompkins, 2006). Many homeless clients and asylum applicants are socially isolated and often experience significant problems such as emotional distress, social inadequacy and alienation, interpersonal isolation and self-alienation (Rokach, 2005). These issues are often compounded by difficulty in gaining or maintaining legal status and being subject to a hostile reception from the general population (Drennan and Joseph, 2005). Internationally, there are differing models and services aimed at providing healthcare for homeless people and asylum applicants (Norredam et al, 2006; Wright and Tompkins, 2006). There is some evidence that assertive outreach programmes for those with mental health problems, supportive programmes to aid those with motivation to address alcohol dependence and informal programmes to promote sexual health can lead to lasting health gain (Wright and Tompkins, 2006). As multiple morbidity is common among those who are homeless, accessible and available primary healthcare is a prerequisite for effective health interventions. This requires addressing barriers to provision and multi-agency working so that they, together with asylum applicants, can access the full range of health and social care services. In Warrington PCT, these research findings prompted us to develop an innovative, inclusive public health service aimed at improving patient care. This was done by extending the reach of mainstream services into unique settings as an ‘outreach’ to marginalised communities that are often fearful of accessing care despite their complex needs (Rokach, 2005; Ghebrehewet et al, 2002). This provision of improved access to healthcare and clinical case management aims to reduce the numbers of inappropriate attendances to A&E and to improve the care these ratients receive. The service works in partnership with local GPs and both statutory and voluntary agencies to achieve quality, patient-centred, culturally sensitive care (Quickfall, 2004). A community-based frameworkWe adopted the family-community health promotion model (FCHP) (Mendoza and Fuentes-Afflick, 1999) as the evidence-based method for delivering care to our patient group. The model was introduced in 1999 by two researchers seeking to understand the epidemiological paradox of immigrant children living in poverty who demonstrated positive health outcomes. The premise is that basic healthcare models tend to rely on three core predictive variables: genetic predisposition, environmental factors and health behaviours. Thus, health professionals often rely on medically derived morbidities and the frequency of healthcare contact to measure health. This approach does not often include functional health - the ability of the individual to manage effectively in their own environment. The FCHP model retains the three core predictive variables of traditional models but adds several new ones. It focuses on the family-community axis more closely than the genetic behaviour axis. The model takes into account genetic predisposition, environment and healthcare systems but also considers the major effects on overall functional health of sociocultural factors, signifying practices, family tradition and the interactions of social services and government agencies. This link is vital to providing public health practitioners with a better understanding of the varied dynamics that impact on client health and their own work. For example, asylum applicants not only experience physical and psychological ill-health due to their history and exclusion, but are also affected by negative publicity. A major supposition of the model is that if a community promotes beneficial health behaviours among its members, these lessons become part of the community signifying practices, resulting in positive behaviours being adopted by individuals who subsequently enter socially excluded communities. This can include dietary preference, alcohol use and core health values. If we can influence these, they will be passed down in the dynamic process of community history and signifying practices (Box 1). Background to the projectThe project began in 2004 when the previous designated health visitor for the homeless and the role was extended to include the asylum-seeking community within Warrington. It has since been developed into a community matron post, based on the expressed and identified needs of patients, who require both health promotion and active clinical case management. The Department of Health’s long-term condition agenda and plans for primary care development (DH, 2006; 2005; 2004) both support drastic improvement in anticipatory, patient-centred care and supported self-care, which are the foundations of our approach to this service and underpin its ongoing development. The service aims to improve quality by being founded in the principles of the inclusion agenda - rights, independence, choice and inclusion - and challenging the stigma often associated with our cultural interpretations of homelessness and asylum (Roche, 2004). These sit comfortably with the underpinning conceptual framework of public health: sustainability, equality and democracy. Of great importance is the formation of sustainable services that are user-focused. Patient health is only protected in the long term if sustainability is built in from the start; we believe it is essential to develop long-term services rather than a ‘quick fix’. The project aims to:

  • Reduce illness caused and exacerbated by homelessness, unstable accommodation, increased vulnerability and the experience of asylum;
  • Promote health and wellness in groups who often lack the motivation and support to achieve these aims.

The service is focused on increasing the ability of patients from socially-excluded and hard-to-reach communities to access existing mainstream services, which is often a challenge as patients frequently express suspicion and lack of trust in statutory agencies. As a result, they depend on unplanned and emergency care. In our area this was the most common way patients from socially excluded groups accessed healthcare, whether for treatment of a minor illness or the escalation of a minor condition into a major health crisis due to a lack of more appropriate care. In general, there are limited preventative services for homeless and asylum-applicant communities; patients are often persistent temporary residents or not registered with a GP at all. The local A&E staff had no referral system to address this issue and refer back into primary care, creating a cycle of repeated contacts with emergency services for primary care needs. Promoting culturally appropriate careWe initially began to address the situation through the provision of a drop-in service that was accessed freely and housed in a non-threatening and safe environment. However, the uptake for this service was minimal, so we looked for other ways to reach this vulnerable client group. Currently we offer a flexible referral service whereby we triage all calls received from key workers and offer an immediate response, an appointment at the most appropriate time and venue or signposting to alternative services. Patients from other cultures often do not understand at a cultural level the concepts that are key to service delivery (Quickfall, 2004), such as appointment times, date of birth and the notion of a ‘health history’. This means the UK healthcare system can be difficult to navigate, especially for those who patients do not speak English fluently or are reluctant to discuss their legal status for fear of being refused treatment or reported to the immigration service. With this in mind, we have attempted to create a confidential and welcoming environment and to positively influence the attitudes of all healthcare colleagues based on Walker’s (1994) valuing difference model (see below). The Valuing Difference model (Walker, 1994)

  • People engage best when they feel valued
  • They feel most valued when they believe that their individual and group differences have been taken into account
  • The ability to learn from people regarded as different is the key to becoming fully empowered;
  • When people feel valued and empowered, they are able to build relationships in which they work together synergistically and on an interdisciplinary basis

Developing the project leader’s role into a community matron post means patients now have an advocate for their health who works in partnership with frontline agencies supporting patients in accessing health, social and voluntary services. Each referral is tracked via a case-finding tool (King’s Fund, 2006) to ensure patients are referred appropriately and record and measure the outcome. This enables us to measure the health and social care needs of the communities we serve and demonstrate key areas for future service development. By having a case manager, patients now have one person to contact and with whom they can coordinate; they have found much easier than engaging with multiple agencies. This lead role has also allowed us to develop strong links within secondary care and we are developing a care pathway for a coordinated discharge from hospital; this may take the form of an offer of accommodation from the homeless housing unit or local night shelter. This will ensure that discharge of vulnerable adults back onto the streets is no longer the only option available. The project is providing improved access to high-quality healthcare, delivered in safe environments with fast onward referral where further care is required. Holistic patient assessments are approached from a public health perspective that includes all aspects of health, with a strong focus on cultural congruency through respecting the understandings and beliefs about health held by the individual. Patients have reported a preference for accessing this service as they find it less judgemental than many of the mainstream services they have previously experienced. A jointly developed pathway for accessing the local out-of-hours service has been developed and gives both the voluntary and statutory sector workers involved in patients’ lives a clearly defined route to take, ensuring that patients access the most appropriate service. Coordination and active case management are used to ensure that patients’ total needs are identified, planned for and met within a model of cooperation and joint working across agencies (DH, 2005). Fragmented care packages are common in marginalised communities, with patients often having to engage with multiple agencies to ensure their holistic needs are met. By providing a holistic assessment based on the single assessment process (DH, 2002), patients have their total needs identified and care plans are produced in partnership with them to encourage engagement and concordance with treatment regimens. By using person-centred and interpersonal communication models, professionals can examine their personal style of communication and establish sound therapeutic boundaries that are based on meeting patient-expressed needs and balance them with positive professional direction and leadership. The person-centred framework incorporates a range of themes that encourage a holistic approach to communication and professional-patient interaction. McCormack’s (2003) person-centred framework articulates many of the themes that are central to nursing practice: mutuality, informed flexibility, sympathetic presence, transparency and negotiation. This allows for full engagement, partial engagement and disengagement within communication, permitting reflection on decision-making and resolving difficult situations. This is important as many patients are not fully engaged when they first access services; this framework allows for therapeutic communication. A potential negative of the person-centred framework is the possibility of conflict for the professional when trying to balance the intensity of the relationship with organisational responsibilities. Shared decision-making is essential in ensuring that patients feel included and in control of their care; it encourages independence, the use of personal resources and patients taking some responsibility for self-care and the therapeutic relationship. By providing care based on their individual desires, needs and abilities, we enable patients to make more informed choices and give ourselves the opportunity to challenge the way services are delivered, to ensure they remain aligned to the real needs of patients. Importantly, this can help in managing the most complex relationships, which are often those with partner agencies and individuals from voluntary or other public-sector services with very different organisational goals and responsibilities. Encouraging everyone to work in a patient-centred way ensures that patient-professional relationships are less about ‘us’ and more about the person we are all engaged in supporting. For example, patients who are seen with chronic communicable diseases are seen as a whole person with accommodation, medication, dietary support and information needs all being met concurrently to achieve improved health. The skills developed in our daily work with individuals, groups and larger communities are centred on negotiating partnerships and cultivating collaborative initiatives that build on the strengths of the communities. As a result, we are ideally positioned to manage the delivery of a wide variety of services within a restructured system that allocates more realistic resources to wellness initiatives. This has already been achieved through the development of initiatives to raise health awareness for vulnerable adults and the extensive health education and promotion work undertaken. Professionals ‘drip-feeding’ information is a slow and ineffective method of improving public health. Within the project we have invested significant time and energy in developing health champions from a variety of backgrounds and services. These include:

  • Homeless unit support workers;
  • Outreach workers for vulnerable adults;
  • Vulnerable adults.

The project also aims to provide strategic influence within the PCT and across the local health economy to ensure the needs of those who are socially excluded are prioritised, planned for and fully included in PCT policy and practice. The service pathwayReferrals are accepted when patients present to A&E staff, out-of-hours services, the local homeless unit or voluntary services with either a health crisis or a minor aliment. They , and their families if appropriate, are then offered a comprehensive health needs assessment by the community matron. Once their needs have been identified, planning takes place with the patient to secure priorities and establish shared decision-making. Referrals to other services are made as required to ensure a comprehensive and cohesive package of care is offered that aims to reduce fragmentation and increase interagency working. If children are involved all efforts are focused on securing safety and fostering opportunities for development, with transference to our local ‘Child and family in need’ pathway if required. Families and/or individuals are reviewed as necessary to ensure continuity of care, leading to increased concordance with care and medication regimens and the facilitation of future access to mainstream services. We always aim to improve our patients’ functional health status and help them to develop sustainable patterns of self-care so they benefit from:

  • Less fragmented care;
  • Fewer unnecessary GP and hospital visits;
  • Improved access to advanced nursing practice from staff with experience of working with vulnerable people;
  • Health action planning for all patients receiving case management;
  • Improved supported self-care opportunities;
  • Clinical care with measurable outcomes.

Within the community matron remit, a database has been developed that supports the recording, tracking and auditing of activity and outcomes. However, many interventions for these clients are short due to their chaotic lifestyles and the high incidence of non-return for follow-up appointments. This means effective audit is not always possible as long-term interventions are not always undertaken for this client group. However, the database has enabled us to track individual episodes of care and determine whether the service is effective by the continued usage by these client groups when experiencing periods of health crisis. We would argue that while clinical case management is effective for marginalised client groups due to the skills and adaptability of the team, one size does not fit all situations and is not an effective solution. Although it is helpful to have one person who is seeing those people most in need, we must have a better method of preventing people from becoming homeless and a vulnerable member of society. Also, by acknowledging that problem behaviour exists, we are then able to work towards minimising the risks to these people’s health. ConclusionPrimary care nurses are at the forefront in delivering the new NHS agenda. Both the health improvement and the long-term conditions agendas have been widely welcomed, however the reality of translating these national agendas into local action is yet to be achieved. Current health policy, focusing on improved primary care, is a timely and realistic response to very real patient needs, particularly those patients who are in vulnerable communities, such as homeless people and asylum applicants. Primary healthcare teams can do much to help patients who are socially excluded to manage their health and well-being more effectively (see below). Advice for primary care teams

  • Consider your own practice and service and think about how accessible it might be for clients who are socially excluded. Small changes such as ensuring information is available in accessible formats and languages and providing a welcoming environment can make a big difference
  • Ensure that homeless people and asylum applicants have access to well-person health checks, health promotion activities and the same health information offered to the general population
  • Find out what local services are already in place for patients who are socially excluded and what the key issues are in the area for homeless people and asylum applicants
  • Remember that homeless people and asylum applicants may already feel let down by, or suspicious of, mainstream services. Ensure they are included in consultations and given time to express their concerns and their anxieties

Homeless people and asylum applicants are people first and foremost. Primary care staff should understand that there is often a greater level of health needs in this patient group; to successfully deliver the primary care agenda patients who are socially excluded cannot be overlooked. ReferencesDepartment of Health(2006) Our Health, Our Care, Our Say. London: DH. Department of Health (2005) Supporting People with Long-Term Conditions: An NHS and Social Care Model to Support Local Innovation and Integration. London: DH. Department of Health (2004) Choosing Health: Making Healthy Choices Easier. London: DH. Department of Health (2002) HSC 2002/001: Guidance on the single Assessment Process for Older People. London: DH. Drennan, V.M., Joseph, J.(2005) Health visiting and refugee families: issues in professional practice. Journal of Advanced Nursing; 49: 2, 155-163. Ghebrehewet, al(2002) Provisionof services to asylum seekers: are there lessons from the experiencewith Kosovan refugees? Journal of Epidemiology and CommunityHealth; 56: 3, 223-226. King’s Fund(2006) (Online) Patients At Risk of Re-Hospitalisation (PARR) case finding, B. (2003) A conceptual framework for person-centred practice with older people. International Journal of Nursing Practice; 9: 200-209. Mendoza, F.S., Fuentes-Afflick, E. (1999) Latino children’s health and the Family Community Health Promotion Model. Western Journal of Medicine; 170: 85-92. Norredam, M. et al (2006) Access to health care for asylum seekers in the European Union: a comparative study of country policies.European Journal of Public Health; 16: 3, 285-289. Quickfall, J. (2004)Developing a model for culturally competent primary care nursing for asylum applicants and refugees in Scotland: a review of the literature. Diversity in Health and Social Care; 1: 1, 53-64. Roche, M. (2004)Complicated problems, complicated solutions? Homelessness and joined-up policy responses. Social Policy and Administration; 38: 7, 758-774. Rokach, A. (2005) Private lives in public places: loneliness of the homeless. Social Indicators Research; 72: 1, 99-114. Social Exclusion Unit (1998) Rough Sleeping: A Report by the Social Exclusion Unit. London: SEU. Walker, B.A. (1994) Valuing difference: the concept anda model. In:Mabey, C., Iles, P. (eds) Managing Learning. London: Routledge. Wright, N. M.J., Tompkins, C.N.E. (2006) How can health services effectively meet the health needs of homeless people? British Journal of General Practice; 56: 286-293. Young, F.W. (2006) Social problems: a focus for a new branch of public health? Social Theory and Health; 4: 3, 264-274.

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