A Pathway project funded by the Burdett Trust for Nursing under their Type 2 Diabetes Prevention Programme recently got underway with the holding of its first workshop on 28 September 2023.
The programme is bringing together specialist diabetes nurses, practice nurses and district nurses with a special interest in diabetes, along with homeless and inclusion health nurses, to learn how to better support patients experiencing homelessness who live with type 2 diabetes.
It was inspired by the work of Specialist Diabetes Nurse and Queen’s Nurse Lynne Wooff (pictured below left), who has done fantastic work with the Bolton Homeless and Vulnerable Adults Team to improve care in this area.
This week, Pathway Nursing Lead Samantha Dorney-Smith (pictured below right), will be visiting Lynne and the team to learn more. Sam said:
“People with diabetes who are homeless are at much higher risk of death and serious complications such as amputations, and they face numerous daily challenges including getting access to healthy food. Through this project we aim to gain a deeper understanding of the prevalence of different types of diabetes in people experiencing homelessness, the challenges of meeting their needs, and the successful approaches we can take towards their care.”
The first online workshop was a huge success, with topics covered including lack of access to care, difficulties with concordance monitoring and treatment, exposure to infection risks, inadequate footwear, difficulties with dental hygiene, mental health issues and concurrent smoking and addictions.
Next up, the project will be running a Nurses’ Meeting in January 2024, plus a second online workshop later the same month focused on understanding solutions. These will be followed by a face-to-face event to share ideas to promote better practice with a view to informing national guidance, and a national survey will also be launched to try and gain the widest possible understanding of the challenges involved in caring for people experiencing homelessness with type 2 diabetes.
Further visits to areas of good practice will also take place, with current plans to visit Bournemouth, Plymouth, St Helens, Leeds and Edinburgh / Glasgow. On top of that, Queen’s Nursing Institute guidance, a Fairhealth E-Learning module and a journal article are all planned.
The project is benefiting from the input of a range of experts including:
Dr Helen Partridge, Diabetes Consultant, Royal Bournemouth Hospital
Dr Daniela Oehring, Associate Professor in Optometry, University of Plymouth
Lynda Dexter, Advanced Podiatrist in Mental Health and Learning Disabilities, Leeds Community Healthcare
Hannah Style, Professional Development Lead Dietitian, East London Foundation Trust / Founder, Feast with Us
Anne McBrearty, Inclusion Health Nurse Consultant, Central London Community Healthcare
For further information about the project please feel free to contact Sam onSamantha.email@example.com. If you are interested in undertaking a nurse-led QI project as part of the programme, this may still be possible, so please do reach out.
On a bright September morning, a group of people gathered in a room in The King’s Fund building in central London. Most of them came from new Integrated Care Systems, the bold and the brave who had signed up – and been chosen – to be part of a new journey to work out how these new systems could improve the health of the most marginalised people in society. All of them were already doing brilliant work in their local partnerships, but wanted to learn from others how to go further and faster.
The evidence for the need for this work is well established but no less shocking for it. Inclusion heath groups are at the sharp end of our country’s health inequalities, with their experiences exacerbated by trauma and marginalisation. People experiencing homelessness are ten times more likely to face an early death than people who are housed. Street sex workers have high levels of multi-morbidity, with 100% of participants in one study having a long-standing illness or disability. Among vulnerable migrants, asylum seekers are five times more likely to have mental health needs than the UK population.
At the same time, there is a reasonably solid body of evidence on approaches that can best meet these needs. Much of this is captured in the recent NICE guideline on homelessness, the principles of which can apply to other inclusion health groups, and in literature elsewhere.
“This is where Pathway, The King’s Fund and Groundswell wanted to shine a light.”
Less well captured has been how ICSs, who are perfectly positioned to do so, can make a reality of the promise of integration for people in inclusion health groups. This is where Pathway, The King’s Fund and Groundswell wanted to shine a light.
The three organisations were approaching this from different but complementary perspectives. Pathway is a homeless and inclusion health charity, supporting a network of specialist homelessness hospital teams and the Faculty for Homeless and Inclusion Health. Seeing patients in hospitals having been so poorly served in the community, we are expanding our activity in system change, looking at what needs to be done beyond the hospital doors. The King’s Fund was, as Toby Lewis, then Senior Fellow, put it, the ‘midwife’ of Integrated Care Systems in the UK from Chris Ham’s time, and continues to lead the thinking on integrated care. And Groundswell’s deep experience in homelessness and health through the perspective of people with lived experience brought critical expertise in this important area.
Our participants, who all worked in different roles and at different levels of their organisations, took part in six sessions with us. They heard from expert contributors from inclusion health, housing and beyond, to whom we owe a great debt of gratitude, who shared the latest evidence-based practice in improving access, outcomes and experiences for inclusion health groups, and ideas about the system changes needed to underpin this. We combined this ‘teaching’ element of the programme with creating space for our participants to think about their own contexts and how they could make a reality of what they had heard in their own areas.
“…many experienced the difficulty of shifting the system’s time, attention and resources to inclusion health groups in the face of so many other urgent and immediate pressures on the NHS.”
The ICSs who participated were all at different stages of their journey in integrating for inclusion health, but they grappled with a number of common challenges. All had pockets of good practice but faced the challenge of spreading services to a wider geographical footprint, while maintaining the principle of subsidiarity. All had some services for people from a particular inclusion health group – often people experiencing homelessness – but had more to do to extend the thinking to other groups such as people who carry out sex work, and people in Gypsy, Roma and Traveller communities. And many experienced the difficulty of shifting the system’s time, attention and resources to inclusion health groups in the face of so many other urgent and immediate pressures on the NHS.
This was a theme in the Hewitt Review, which made the case that “prevention, population health management and tackling health inequalities are not a distraction from the immediate priorities: indeed, they are the key to sustainable solutions to those immediate performance challenges.” We would agree, as would our participants.
Certainly, system reform, driven at national level, is needed to make the task of ICSs easier. Data systems need an overhaul to address the invisibility of inclusion health groups in data, with its consequences for planning and commissioning. Workforce training and education needs to be updated to give the front line the skills and experience to work in a trauma-informed way. Housing precarity is a horrific drain on the spirits and the health of people in inclusion health groups and requires urgent Government (or devolved mayoral) action to provide more affordable and stable housing, with support for those who need it.
“ICSs do not need to wait to take action…”
ICSs do not need to wait to take action, however. Our programme showed many reasons for optimism, and that there are concrete, immediate steps that ICSs can take to tackle the sharpest of health inequalities experienced by people in inclusion health groups. We have captured the best of these from our programme in the report we’re launching today. The report outlines a roadmap for inclusion health – seven steps that ICSs can take to address their challenges and make a reality of the promise of ICSs. Perhaps the least developed step is the last: to use the power of their Boards, and the reach of their partnerships, to test and evaluate whether services really are accessible and available to those most in need.
We offer this with a degree of humility. We know what works, but ICSs are still learning about how to operationalise it, and we’re learning alongside them. Today, we are also launching a new network for leaders and managers in ICSs, to come together to share learning and experiences in how best to care for the most underserved people in their area. This is a new sub-group of our long established Faculty for Homeless and Inclusion Health, to be led by Jon Pritchard, Associate Director of Housing at Southern Health.
We will continue to gather these insights and hope to run another programme for another set of ICSs. In the meantime, we want to encourage you to read this report, and take the lessons into your own local system. People in inclusion health groups, living daily with the consequences of the failure of our health and care systems to genuinely care for them, deserve nothing less.
I started thinking about medicine as a career at 17 years-old, following a bicycle accident where I was taken into hospital. Before this, I had been set on a career in law and had hated sciences, dropping them as soon as I could after GCSEs. However, I was really touched by how compassionate the care I received in hospital was, and the idea of caring for people as a career really appealed to me. I undertook some work experience to find out more about medicine, and was struck by how continuous and empathetic primary care can be, shaping health outcomes, particularly amongst marginalised patients. Somehow, I found a course that would take me with no science background and went off to study medicine at the University of Manchester.
However, my experience of healthcare whilst studying medicine has proved very different to my expectations. I have studied medicine in an NHS that feels overburdened. My GP placement, instead of focusing on continuous care, felt like it was about seeing the largest number of patients in the shortest time possible. I have seen care from some amazing professionals, but structural pressures have seemed to limit their impact, and they have been forced to make decisions that do not provide the best care. I have also seen some care from professionals who seem burnt out and to have lost their ability to empathise with patients. This empathy apparently peaks in second year of medical school, so I am already on my way down.
“This sector is a real testament to the passion and determination of the people who work in the NHS…”
Towards the end of our medical training, we can undertake an elective placement in an area of our choice, which I decided to undertake in inclusion health. I have spent a month shadowing at a GP practice for people experiencing homelessness, and at Pathway, which focuses more on secondary care and structural changes to improve healthcare for this group. During this placement, I have been moved by the way the healthcare professionals in this field fiercely advocate for those in their care, making sure both their health and non-health related needs are recognised. This sector is a real testament to the passion and determination of the people who work in the NHS, and to what can be achieved if some of the pressures placed on mainstream practices, such as 10-minute GP appointments, are alleviated. It has been a privilege and truly inspiring to witness the hard work that goes into providing health equity for people experiencing homelessness.
In one year, I will be graduating, in what seems like a turbulent time for the NHS. I do have concerns about graduating. I’m worried that I will feel that, because of external pressures, my practice is not safe for patients, or that I won’t have the time or the resources to provide the compassionate care that I received in hospital, and that drew me towards the NHS in the first place. I am also concerned that I will be part of a system that fails marginalised patients, and instead of providing long term, sustainable support, sends them back to the conditions that made them sick in the first place.
But I am, above all, grateful that I will be able to work in a National Health Service, with people who are so passionate and caring, and from whom I have so much to learn.
I was born in 1965, when the NHS was in late teenage. My first memories of being a patient are visits to the local GP at the surgery attached to his house, and home visits when having treatment for ‘bronchitis,’ later called asthma. In my own teenage years my asthma led to quite frequent weeks away from school until a change of treatment to a new ‘puffer’ sent me from being a wheezing wreck, last by some margin in weekly winter cross country, to coming in third or fourth, and not always having to go in goal in football!
I started medical school at the time of the miners’ strike. With a full grant and fees paid by the local authority, our moans about late cheques seem very churlish now when compared to the huge student debt faced by those who followed just a few years later. Patients in the teaching hospital seemed to have excellent care from dedicated staff, but threats of financial cuts had us marching on the streets of London regularly in the mid to late 80s.
“On some nights, some sleep was possible…”
On qualifying as a doctor in 1989, it was a massive relief to be leaving medical school, although it brought entry to a world of working overnight a couple of times a week (while still doing the day job) and four-day working weekends (day and night) two out of every five weekends. On some nights, some sleep was possible, but the ever-present thought of the emergency bleep going off, leading to a run across the car park while getting dressed, meant that proper rest was unlikely.
The change to General Practice brought a more reasonable life. No more hierarchical hospital structures, and ‘on-call’ meant driving around dark streets looking for patients’ houses, rather than dashing to a cardiac arrest. This soon turned into shifts in the new GP Co-op and then no on-call at all when GPs voted to give up 24-hour responsibility for patients. This perhaps marked the start of a diminishing continuity, but at the time felt like a massive step forward for GPs’ wellbeing.
“We opened the doors with a patient list of zero, growing to 700 within a few years. The need was overwhelming and some of the patients severely ill…”
A change in NHS legislation to allow employment of GPs outside of traditional partnerships led to a post as a salaried GP in a Personal Medical Service (PMS) pilot in Brighton, in 1998. The surgery was new and aimed at providing a service to people who were experiencing homelessness. We opened the doors with a patient list of zero, growing to 700 within a few years. The need was overwhelming and some of the patients severely ill, both mentally and physically. Developing the surgery with Substance Misuse services, the Mental Health Team, midwives and outreach services was hard but rewarding work. Maintaining a work/life balance with a young family was also difficult, but just about possible.
After six years the local health authority moved the surgery management from a Community Trust to a commercially minded ‘private NHS company’, with disastrous consequences. Opposing ways of thinking about health (patient centred vs profit driven) became untenable, especially when departing management staff were replaced by others with no experience, interest or understanding of what we were trying to do.
“The NHS can benefit greatly from such new ways of working…”
Eventually, after four years of increasingly difficult relationships, the company made us all redundant and we were sad, but relieved, to go. Soon afterwards Pathway, the Inclusion Health charity, approached me to lead an arm of a clinical trial into the Pathway approach of GP led in-reach teams. The trial was successful, and the Brighton Pathway team is now in its 11th year. The NHS can benefit greatly from such new ways of working, welcomed in some places, yet still rejected in others.
After a few years, the company at my old surgery handed back their contract, threatening it with closure. Along with clinical staff at the surgery, we created a Community Interest Company, ARCH, to bid for the contract. We were successful, and within two years of taking over gained a CQC rating of ‘Outstanding’ in all areas. This year we have been awarded a seven-year contract for a service bringing together Primary Care for 1,400 patients, hospital in-reach, outreach, and step-down services. Quite a journey from the pilot surgery with no patients in 1998!
“…the NHS is the people within it.”
During my years of practice, perhaps the most significant thing I have learned is that the NHS is the people within it. Most of them are dedicated, caring, and fiercely protective of their patients and services. However, increasing numbers feel undervalued, downtrodden, and questioning of the future, while younger people joining the service question whether to go somewhere where they will be appreciated (and paid) more. We ignore their feelings at the peril of an organisation with the goal of health equality at its heart, and one which we all wish to see thrive for another 75 years.
With A&Es under so much pressure right now, it may seem like a difficult time to launch any new initiatives for them. However, it could also be argued that this is really the perfect time, as it is when systems are under pressure that we know we can all make mistakes, and things can get missed.
I actually started my ‘career’ in Inclusion Health when I worked in A&E. It was there that I first came face-to-face with people experiencing homelessness, and started to learn something of their lives and the challenges they face. I was the nurse providing tea, sandwiches and blankets, letting people sleep in the waiting room overnight, and quietly shooing them out in the morning! Kind maybe, but it never once occurred to me to try to get them housing or connect them with community services.
Twenty years on, and my perspectives have obviously changed, but I have a very clear memory of what it was like to work in A&E, and I have many colleagues still there now. I know how difficult it is.
We also hope that the E-Learning will support the development of a network of Homeless and Inclusion Health Leads in A&E departments, so if you are one of those people, please don’t hesitate to get in touch with us at firstname.lastname@example.org.
Adrian Boyle, President of the Royal College of Emergency Medicine, said:
‘Looking after people experiencing homelessness can be very difficult for many emergency clinicians. This patient group frequently have serious illnesses and have sometimes dreadful experiences of healthcare. This resource will be invaluable for equipping clinicians with useful knowledge to look after some of the most vulnerable people in our society.’
Pete B, Pathway Expert-by-Experience and course contributor, said:
“I am grateful I had this opportunity…embrace what’s trying to be delivered and use it to capture your understanding and empathy.”
You can access the E-Learning here on the Fairhealth website, along with many other free courses on Inclusion Health topics.
As the Homelessness Reduction Act marks its fifth anniversary, Pathway Policy Officer Emily Page looks at the ongoing benefits and challenges presented by the Duty to Refer.
On the 3rd of April 2018, the Homelessness Reduction Act was implemented across all local authorities in England; a fundamental reform in homelessness legislation which put prevention at the heart of tackling homelessness.
The Act placed a duty on specified public authorities to refer service users who they think may be homeless or threatened with homelessness to a housing authority. The Duty to Refer was intended to encourage local authorities and other public bodies to build strong partnerships, enabling them to work together to intervene earlier to prevent homelessness through increasingly integrated services. It would ensure that people’s housing needs were considered when they came into contact with public authorities.
We know that health services such as emergency departments, urgent treatment centres, and inpatient care services treat people at risk of, or experiencing homelessness, everyday:
In 2022, 2388 patient referrals were accepted by 9 Pathway hospital teams across the country.
That’s why, five years on, Pathway is collaborating with Crisis to explore how the duty is working in hospital settings and the extent to which the legislation is working to prevent homelessness. Together, we convened conversations with local authority and healthcare staff across five localities in England to discuss how they feel the duty is operating in their area, provide a space to share best practice, and identify any difficulties and barriers in implementation.
Staff remained candid yet hopeful throughout the discussions, recognising that the Act and subsequent duty were a step in the right direction, with some staff reporting improvements in local discharge processes and integration between services.
Laudable though these aims may be, staff also highlighted that successful implementation of the Duty is mired in systemic challenges, including, most fundamentally, the lack of appropriate and accessible housing options on offer for patients with complex needs:
‘’It’s hard to do any real preventative work when you’re constantly firefighting’’.
‘’In a nutshell – there isn’t enough accommodation – the complexity of need just isn’t met’’.
To read more about the obstacles impeding the Duty to Refer in practice and recommendations for how we might mitigate them, look out for the report of our review, to be published in Spring 2023.
Inclusion Health had never been a subject I knew much about, until I began an extended research project under the supervision of Dr Lucy Chiddick. Dr Chiddick offered something new to my previous medical education: an opportunity to explore healthcare for people experiencing homelessness. This seed of interest in Inclusion Health was further nurtured during a leave of absence from my medical degree, during which I undertook a master’s degree in Humanitarianism and Conflict Response at Manchester University.
The course was extremely varied, covering international relations, anthropology, public health, climate change and historical analysis. It also opened my mind to concepts of what constitutes personal identity, and how this interacts within society in the context of structural forces. I subsequently began applying this knowledge to encounters with patients I saw in Manchester when working as a healthcare assistant across three General Practices. Each practice served different demographics facing varying health inequities and barriers to healthcare. The opportunity to observe and actively take part in community interventions for health promotion tailored specifically to marginalised groups was invaluable, whilst also allowing me to contextualise my knowledge in real healthcare scenarios.
“I found a huge amount of information and literature from differing sources, however it became clear to me that there was no one resource that collated all the necessary content…”
My passion for health advocacy grew after these experiences, however I was still left with many questions. Why hadn’t my medical school instilled this passion within me to advocate for marginalised patient groups? Why hadn’t social determinants of health been contextualised in the lived experiences of individuals? Why hadn’t it been demonstrated to me that this knowledge could be actualised into health interventions to affect real change? I became curious about the societal structures homeless patients existed within and what support was available. I found a huge amount of information and literature from differing sources, however it became clear to me that there was no one resource that collated all the necessary content into a simple, digestible format for students to learn from.
Subsequently, I set out to fill this gap in the medical curriculum. I aimed to create an e-module that not only spoke on how to provide healthcare to people experiencing homelessness, but also answered the wider questions I had regarding legislation, housing systems, how people become homeless, and the non-homogenous experiences of homelessness. This information is crucial in contextualising homeless patients within structural systems of oppression that disproportionately create vulnerabilities to becoming homeless. It also counteracts widely held beliefs that homeless individuals are at fault for their situation and ill-health, instead encouraging students to become advocates for homeless patients. With the support of the experts at Pathway, and Dr Dominic Patterson who provided me with the platform to create this learning tool, I was able to complete the e-module ‘A Student Healthcare Guide to Supporting People Experiencing Homelessness’, now available on the FairHealth health equity learning website.
“During my inclusion health journey, I also found many likeminded students who were similarly passionate about this content and undertaking incredible initiatives at their own universities.”
I hope that this learning resource contributes to the efforts of the many other professionals and students advancing inclusion health education within the curriculum, and that it may be used not only by healthcare students, but also as a tool for educators in the design and implementation of similar teachings envisioning the improved healthcare of homeless patients.During my inclusion health journey, I also found many likeminded students who were similarly passionate about this content and undertaking incredible initiatives at their own universities. However, on the national scale these efforts were fragmented and isolated from one another. There was a missed opportunity for collaboration and resource sharing between students and professionals in the field. The Faculty for Homeless and Inclusion Health Student Network, hosted by Pathway, is a national organisation that aspires to change this. It has three primary aims: education, collaboration and advocating for inclusion health. Its committee provides a place for students, professionals, Experts by Experience, and other key workers to network and promote learning and research opportunities.
The Pathway Partnership Programme was recently announced as the first prize winner of the London Homelessness Awards 2022. Following the awards, LHA spoke with our CEO, Alex Bax to ask him what it meant to win the award and to discuss Pathway’s plans for the future…
Winning the award has been a huge validation for the team and has highlighted the wonderful work our Partnership teams do across London. When you’re in the thick of it day to day, it can sometimes be hard to see the impact you’re having. But this success reminds us of the role we play, and further shows the value of our work to our external partners.
Overall, this award also confirms the trajectory we’re on: to spread the model and aim for controlled but ambitious scaling up.
I recently took the trophy to the St George’s Homelessness Inclusion Team’s one-year anniversary event. This brought a real focus about the next year and where the next round of funding might come from. And showing the video helps us all to think about the work we’re doing. We intend to make more use of the film in national meetings as well to show partners and stakeholders across the country the impact Pathway teams can have.
And of course, the £30,000 prize money is helpful. It allows us to think more about where we want to be positioned in the system and where we structurally fit. With the changes from CCGs to ICBs, things are very fluid right now.
A key theme for us is that in our population there are lots of lives impacted by trauma, and our staff often work with very traumatised individuals. This in turn can have an impact on our teams – for example, if other services refuse access, our staff can be left with deeply vulnerable people who have been turned away. It is often our teams who must give out the bad news and manage the fallout, which can be a very distressing situation for both the patient and the team.
To address this, we have engaged with psychologists to work with our teams and help equip them to deal with the trauma that surrounds them. This also equips the team to deal with the complex behaviours that traumatised people often display. We need to remain compassionate, kind, and consistent, and the psychological support helps with this. We will use some of the prize money to not only fund this support but also to develop the evidence that shows that it works and delivers good value for money for other funders.
If you are thinking about applying for the London Homelessness Awards next year, I’d say that it is a hugely worthwhile process all round. The application was not too onerous and helped us to think about what we are doing and why. The judging visit was also very insightful and raised powerful questions.
Our success in the awards has also opened doors – for example, I am meeting with the London Directors of Housing in January, and have had good meetings with borough Chief Execs following the awards.
The London Homelessness Awards have been good for us as an organisation and as individual team members. I’d encourage everyone in the sector to think about applying.
For more information about the London Homelessness Awards go to lhawards.org.uk.
The Pathway Partnership Programme was recently announced as the first prize winner of the London Homelessness Awards 2022. Following the awards, LHA spoke with Danielle Williams, the GP and Clinical Lead for the St George’s Homelessness Inclusion Team to find out more about her role.
Hi, and thanks for talking to us. Who are you and what is your role?
I’m Danielle Williams, a GP and Clinical Lead for the Homelessness Inclusion Pathway Team.
And who else is in the team at St George’s?
We take a multi-disciplinary team approach (MDT). As well as me, there are two nurses – one full time in the hospital and one part time in the community. We also have two housing workers and a care navigator. They are all brilliant!
Where do you get your clients from?
We receive referrals from across the hospital – A&E, wards, outpatients. Anyone in St George’s can be referred to the team if they are rough sleeping or at risk of homelessness.
And what do you aim to do with and for your clients?
Our main aim is to support patients with their health and to prevent early death. We start with a holistic assessment; we look at their health, but not just the reason for admission. We consider any other chronic conditions, engagement with GP, engagement with addiction and mental health services, and look at their housing, benefits, immigration and any other needs. The aim is to pull together all sections so that we can support them during their admission. We want to make sure they are engaged with their health care, and can advocate for themselves, or ask us to do it with them. The idea is to look at the big picture, making every contact count. To do this, we liaise with multiple different teams in the hospital and community – housing, alcohol, drug and health to ensure they are linked in with the right services.
What about when they leave hospital?
Our role is to try to help support a safe discharge and ensure our patients have all the right community support in place. We can continue to support in the community for up to six weeks after discharge. We work across many different boroughs and so we are often working with a range of councils to get the discharge right.
Can you give me an example of someone you have worked with?
One patient of the team was a frequent attender after a previous wound from an assault. He was rough sleeping and getting recurrent infections and had had dozens of admissions. We worked with him to help advocate for him to get better secure safe accommodation when he left hospital. We also helped him to engage with his GP, family, and community teams. Since that time, he has been doing really well and has had just one admission.
Another patient of the team was rough sleeping and using heroin. He presented after an injury and required several surgeries. He found it difficult to engage with his medical care initially, missing follow up appointments, not taking his antibiotics and self-discharging. Our team supported him to engage with his medical care and attend his appointments. We liaised with community teams including supporting him to make a homelessness application and were able to advocate to the council to ensure the council placed him in safe suitable accommodation. We supported him to register with a GP and engage with local and drug and alcohol services. He now sees his GP regularly and continues to engage with hospital medical care and drug and alcohol teams and is no longer taking street drugs. He has been able to reconcile with his family, is back in a happy relationship with his partner and is back in his children’s lives.
Today, I have been in A&E and on wards and my colleagues are out in the community helping clients meet appointments go to GPs, etc. We often go to community meetings to be the hospital voice and support with housing issues, advice and applications. We also try to be a bridge between primary and secondary health care.
Have things got worse?
Life is tough for many people at the moment but particularly for those experiencing homelessness. We help to bridge the gaps. The MDT approach works well. Patients have often lost trust in the system and need someone to take their side. Yes, sometimes it can be a fight, and it can be tough, but helping people in tough situations is why our team is here.
I want to start by thanking my colleagues for being such a support over the years. I can’t name check everyone but:
I must remember Aidan Halligan, our founder, inspirational speaker, and enthusiast for confrontation, who made so much progress possible.
Trudy Boyce and Florence Cumberbatch, whose boundless compassion is a helpful counterbalance to my heartless setting of boundaries.
Stephanie Swan, whose hard work and dogged financial prudence has ensured that our charity has thrived when many others have not.
Alex Bax, with his commitment, renowned political nous, and world class schmoozing skills.
Stan Burridge, and his team of EBEs with their resilience, energy, and challenge.
Chris Sargeant, my successor, hugely experienced, involved in Pathway and the Faculty from the start, and a clinical leader for our future.
And Sam Dorney-Smith, who never says no, and always, always gets the job done.
So, I can’t help a bit of looking back, but mainly with the aim of looking to the future.
I remember studying for my A levels in the early 70s by candlelight, when Tory tax cuts and the OPEC energy crisis had led to power cuts, the three-day week, massive unemployment, run-away inflation, and widespread poverty. I later understood that this societal trauma resulted in the many socially excluded people of my age that I went on to work with over the years. So perhaps there may be some lessons to be learned from the past!
Everything useful I know, I have learned from my patients, but clinicians still tend to be the ones who apply labels to things, so I have three labels to consider: heroic narcissism, moral injury and finally, Inclusion Health.
Heroic narcissism,the conviction that you are the only person that can save a person or resolve a situation. This is a particular personal risk for people drawn to our sort of work. But even looking back at my mainstream practice, I later realised that many of the patients I labelled as “heart-sink” patients were actually experiencing complex trauma and personality issues, and we drew each other into a co-dependent spiral of unmeetable demands and projected feelings of inadequacy and despair. I was convinced that I was the only person capable of keeping them alive. Years later, imagine my indignation, when I would bump into them at the supermarket, evidently alive and thriving without me!
Heroic narcissism is also a risk for our organisations which can mirror these dysfunctional relationships. This is abetted by a system of short term and competitive funding that leads to more splitting and drive to compete. Housing First versus Housing Ready, street outreach versus institutional in-reach, critical time interventions versus long term relationships. In fact, these are all false dichotomies; there is no shortage of people in need, and we need a variety of responses to help each person in their particular situation.
Moral injury is a term that came to the fore during the pandemic, but I recognised the experience when I saw it described. Moral injury is a damage to our values when we feel ourselves complicit in a morally wrong situation such as failing to treat undocumented migrants or discharging people to the streets. Moral injury can lead to cynicism, burnout and despair and is a real risk for all of us engaged in this work. Particularly now, when our government, after years of austerity, the financial crisis, the pandemic response and now the energy crisis and economic mismanagement, are ensuring that inequity is growing. More children are growing up in poverty and trauma and heading for long term ill health and multimorbidity. So, at least to look on the bright side, you too are all guaranteed long careers in a growing field over the coming decades.
So how can we keep going despite moral injury in difficult times? I guess the first lesson is to beware of heroic narcissism. We are all driven, passionate people but remember, it’s not all on you. Take your holidays and days off, look out for sabbaticals, find help when you are struggling. Everything changes and no-one is indispensable. Choose your battles, be ready for change, and think about seeking new roles and different opportunities every once in a while.
In my view, being a good clinician is very like parenting. Perfection is impossible and excellence is rarely achieved. Just try to be consistent and accept that the best that most of us can manage is to be good enough most of the time. To be honest, it’s all I reasonably want from any clinician in whom I’m putting my trust.
So, the final label to consider is Inclusion Health. It’s 10 years since the first annual conference of our faculty, when we came together as a scattered and isolated collection of clinicians and experts by experience to support one another and improve outcomes for our patients. Together, we have built an impressive evidence base and taken inclusion health from a made-up word to a real job title for health service leaders and a core value of the NHS.
As we face an uncertain future, we at least have the knowledge that over the last thirty years we have gathered the evidence about how to do this work well. We know that we must be kind to our patients, kind to our colleagues and kind to ourselves. Build and foster relationships, and follow the key evidence-based inclusion health approach that we summarised as individual care coordination supported by a multi-agency team. So once again, thank you all for your support.