‘ Getting people to engage with the alcohol service is much harder than the drug service ...’ Paul Daly
Steve Phillips / Jeff Gilbert / Alamy Stock Photo
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‘ Getting people to engage with the alcohol service is much harder than the drug service ...’ Paul Daly
Coming through the door at CHIP represents an opportunity . ‘ A lot of the time we find you have to do everything while the patient is right there in front of you ,’ says Daly . ‘ The minute they go out the door , you lose them again .’ Seeing them regularly gives a chance to address longer-term health conditions – although he points out that , sadly , many patients living in the harsh environment of the streets don ’ t actually survive long enough to develop late middle-age conditions like diabetes and COPD .
But having them in front of you means prescribing what they need : ‘ You want them to come back , and if you take a rigid approach to it they won ’ t come back at all . Then we can work on their other issues – it ’ s a different concept of medicine to a mainstream practice .’
It ’ s a ‘ massive challenge ’ for the clinicians , he adds , as making a judgement on what to do with complex cases can be really difficult . The team ’ s weekly meetings are a focal point for agreeing the way forward for each patient , bringing in the other services as needed , or attending multi-disciplinary meetings outside . Complex patients might need expertise from mental health , drug services , social services , police and safeguarding .
With the dialogue created around their healthcare comes access to many sources of help . A hepatology consultant visits every two weeks from the local sexual health clinic and is ‘ bombarded ’ with patients wanting the new hepatitis C treatment . At ‘£ 40,000 a throw ’ triage has to operate , through assessment by a panel .
Patients also have the opportunity to see an HIV consultant who comes in every fortnight , and there is support available for mental health problems and personality disorders . Many patients are referred to the specialist alcohol service in Camden , and Daly comments that ‘ getting people to engage with the alcohol service is much harder than the drug service ’.
The Citizens Advice Bureau ( CAB ) worker comes in once a week to help with benefits and housing – and is even more in demand since the benefits system moved online . Another vital visitor is the tissue viability nurse , who comes in one a month to support the nurses and do the more complex dressings . ‘ We have patients who have huge leg ulcers because they ’ ve been injecting for years ,’ says Daly . They might come to CHIP for a while , especially if they have come out of prison , and the nurse will get the leg to a point where it ’ s in a good state . ‘ Then they ’ ll disappear and turn up two months later with the same dressing on , and it ’ s all gone back to square one again . It looks like something from a war zone .’
Unsurprisingly , the team who run this service ‘ go over and above quite a lot ’, whether it ’ s paying for an asylum seeker ’ s life-saving medication while paperwork is sorted or calling in the crisis team to help a patient with a mental health issue that might take hours and ‘ blow the clinic ’ s schedule apart ’. Producing calm from chaos has become second nature to a team that focuses on stabilisation in all its contexts .
There is naturally cross-referral of patients with the drug service upstairs , but the commissioning structure does not make this as easy or logical as it could be with CHIP being commissioned by NHS England and the substance misuse service commissioned by public health .
But Daly is appreciative that the CCG and medicines management team understand the nature of a homeless practice . ‘ You can pay £ 35 just for one dressing , so our dressings budget is through the ceiling . And our antibiotics budget is a lot larger because we have a lot of infections .’ Furthermore , there are no predictable attendance patterns from one day to the next , summer or winter .
If the service was on TripAdvisor , they might have five star ratings ; an equivalent endorsement would be those who still come back long after they ’ ve moved away . ‘ People don ’ t want to leave us , so there are patients that have been here for 20 years ,’ says Daly .
Sadly this may need to change as NHS England have told London homeless practices that nobody can stay registered with them for more than 15 months . ‘ The theory is that after 15 months with us they will be cured and ready to go back to society ,’ he says , ‘ so you have to move everybody on , which is totally unrealistic . It was obviously written by somebody who has never come to a practice .’ DDN
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