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Super nurse

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Sheer determination and talent won Nicky Hepden a top NT Award, writes Louise Hunt.

This year’s NT Awards saw the launch of the Chief Nursing Officer’s Award – a merit dedicated to a nurse who has demonstrated strong clinical leadership and achieved real benefits for patients.

It’s inaugural winner, Nicky Hepden of Berkshire West PCT, who leads a clinic for society’s hardest-to-reach clients, couldn’t have come with a stronger recommendation. Nominating her for the award, the trust’s director of clinical services Anne Owens said: ‘Nicky has provided exemplary leadership and engendered the same passion in her team for delivering the highest-quality service.’

Nicky herself is keen not to take all the credit, giving her own plaudits to a ‘fantastic, like-minded team’, but it’s clear that her tenacity for working with homeless and other vulnerable people and her part in helping to establish and lead the Baker Street Clinic in Reading earned her the Territorial Army-sponsored commendation.

The drop-in service, based in a street of the same name, was opened in October 2004. It was initially aimed at providing health services to homeless people but has since expanded to cater for all hard-to-reach people who have difficulty accessing mainstream healthcare, including sex workers, those living in temporary accommodation, travelling communities and asylum seekers.

‘The Baker Street clinic is about providing a healthcare route for people who haven’t got one,’ she says. One of its primary aims is to stabilise clients so that they can be moved on to see GPs.

Ms Hepden explains that the complex and chaotic lives of her clients often means they have great difficulties accessing mainstream care, in particular getting on to GP lists. Many frequently suffer from severe physical and mental health problems. Research by the Queen’s Nursing Institute Homeless Health Initiative found that homeless people are 40 times more likely not to be registered with a GP, and subsequently they are four times more likely to inappropriately use A&E services. The life expectancy for those sleeping rough is 42.

The inspiration for Baker Street came from Ms Hepden’s previous work providing a health service at the Churches in Reading Drop-in Centre. Having long had an interest in homeless nursing, she applied for the newly created part-time position in 2001.

The big draw for this service was that it had an open-door policy, where clients could use the facilities at any time as long as they followed the rules, she says. Having practice nurse experience, covering areas such as diabetes, asthma and family planning, helped her to offer an all-round service.

Unfortunately, the post was short-lived as concerns for her safety led to her being withdrawn from the service. ‘I was a lone worker in a back room and there were a couple of incidents where I became very frightened.’ From this experience she drew valuable lessons that are applied at the Baker Street service today, with protocols in place that include always having another member of staff in the clinic or when undertaking outreach.

‘I learnt safety is a priority. This is a very difficult client group to work with; most of it is detective work in finding out their background as a lot of them have mental health and drug issues.’

But the silver lining came in the development of the Baker Street Clinic with Vera Azuike, who was then operational line manager for community nursing at the trust and a supportive force in Ms Hepden’s work. Realising the need for a nurse-led homeless clinic, together they put together a business plan and proposals for funding, working with the trust’s public health department.

After several attempts, they were successful in securing one of the last Primary Medical Services grants, which provided initial start-up and staffing costs and Baker Street was established in a disused factory.

The clinic is now funded by the PCT as a provider service. Led by Ms Hepden, it employs a part-time team of two senior staff nurses, Romy Spindler and Helen Thomson, and health visitor Christine Ramshaw.

‘We have developed pathways to offer a one-stop-shop with enough expertise to provide complete episodes of care,’ she says. Ms Hepden and another staff nurse are extended prescribers. The team also has the support of a local GP with special interest in substance misuse, who acts as a friend to the service, providing training and advice.

Ms Hepden says: ‘The clients are forever pushing the boundaries with us. We are acutely aware that we should only prescribe within our areas of responsibility. But when you have a client with a multitude of complications you have to tease out what will be the best treatment. Often they don’t want antibiotics but Valium. You have got to be very assertive and confident. They can be little toerags at times but they are also great fun to work with.’

Along with carrying out assessments and educating clients, advocacy with other health services is a large part of the clinic’s work. ‘Part of our role is to make our profession understand the complexities – people do make terrible judgements of these groups.

‘Baker Street steps in by stabilising clients to help them find a GP again, especially if they have chronic conditions. By stabilising we explain why they are not being seen, for example if they are drunk or smelly or rude. Sometimes their expectations of what a GP can do for them are too great. Once they have accessed a GP we back off but if the problems come back we step in again.’

The teams visit clients all over Reading seeing 2,500 people a year. ‘I recently did a consultation in a car park,’ muses Ms Hepden.
Some of her most memorable success stories have been achieved through these networks. One is of a young lady who was a well-known rough sleeper and notorious street beggar with a £300-a-day heroin and crack cocaine habit.

‘As part of a network, we identified this lady needed a lot of support in getting into housing after there had been three or four previous attempts. By working with the different partners we got her into a Salvation Army hostel and on to a drug and alcohol addiction treatment pathway, with support and health input from us and a GP. Now she has stabilised and has been given a small flat and is going back to college. She has her whole life ahead of her.’

She adds: ‘These are the dramatic successes but success is on so many different levels – a client coming back to the clinic for example. We are respected by people on the street who have learnt to trust us. If we can’t help them we will tell them where to get help.’

Summing up Nicky’s achievements, chief nursing officer for England, Chris Beasley, said: ‘Nicky demonstrated caring and compassion coupled with determination and business acumen, successfully setting up a service for some of the most disadvantaged and marginalised people in society.’

• Pull together all evidence using local and national data, including information on homeless access to GP services and impact on clients’ health and health services such as A&E
• Hold meetings with stakeholders to gain support and establish a steering group
• Demonstrate how the service will be developed, including care pathways and use of other agencies
• Research by visiting similar services in the UK
• Broaden client remit, if struggling to gain funding. Baker Street was successful on its second Personal Medical Services grant application when it decided to extend the service to asylum seekers and refugees, which added weight to its bid
• Adapt protocols and guidelines to be nurse-led service specific, for example on health and safety issues and prescribing
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