This action plan is an evolving, practical plan and there are active discussions with colleagues across the NHS, local government and the charity sector about how to mobilise resources to deliver this plan. It is based on the established principles in managing any epidemic. Separate infectious people from non infectious people, keep them apart. Care for and support both groups.
Statement in response to new UK Government guidance, 17 March 2020
Pathway is deeply worried that the guidance issued by Public Health England yesterday (16 March 2020) fails to address many of the practical concerns being raised by specialist homeless clinicians and the homeless charity sector across the country.
We are already hearing reports that following the guidance is resulting in homeless patients being told by NHS 111 and local authorities to go to A&E. At the same time A&E colleagues in at least one central London hospital report telling people with mild symptoms to go back to the street. Homeless patients very obviously have nowhere to go and self isolation on the street is not possible!
Professional colleagues in infectious disease epidemiology and in the clinical management of homeless patients have been working on a detailed plan to look after homeless patients with compassion and care, and to avoid a serious spike in Covid 19 infections in the homeless population in London. The plan proposes rapid, active testing for Covid 19 in all London’s homeless services, separating homeless patients who test positive from those who are virus free, and setting up new emergency temporary facilities (perhaps in hotels or other currently available vacant buildings) to care separately for each group.
“Test – Triage – Cohort – Care.”
To be effective we need the NHS, homeless charity sector, local authorities and public health services to mobilise resources rapidly. Delay will increase the level of background infection and reduce the effectiveness of measures to isolate vulnerable patients.
People experiencing homelessness are a very high-risk group. Compared to the general population people experiencing homelessness are 2.5 times more likely to have asthma, 6.5 times more likely to have heart disease, 10 times more likely to have COPD and 34 times more likely to have tuberculosis. Long-term homelessness is already associated with a mortality risk 10 times that of the housed population.
Pathway’s CEO Alex Bax said: “People on the street are by definition vulnerable to infection. The homeless population has very high rates of all the conditions known to increase the serious risks of Covid 19. We need rapid, co-ordinated action across all services, underpinned by clear clinical leadership and based on a coherent plan. The Government has said resources are available. We need to see them start to flow now, and crucially this means access to testing.”
The closing session of our annual conference yesterday was amended to give an update on the challenge of COVID-19.
Professor Andrew Hayward (UCL Professor of Infectious Disease Epidemiology and Inclusion Health) and Dr Al Story Clinical Lead, Find and Treat, produced this slide set.
We are sharing these slides so that organisations and individuals can start to think about what this virus will mean for their services and the people they help.
This is not official Public Health or NHS advice, this is still being prepared, but this is the latest available expert view from our colleagues.
The last three slides may need a bit more explanation:
– A radical change in service delivery is likely to be necessary.
– Outreach virus testing for all rough sleepers as they are particularly vulnerable.
– Closure of no second night out to avoid kettling vulnerable and undiagnosed people together; but consider re-purposing NSNO for screening and triage. “Cohorting” means grouping into three categories:
o Virus free – hotels or tent parks, with food, sanitation, support and “relaxed” policing of those with active drug and/or alcohol needs.
o Covid-19 positive or suspected, but not severely ill – as above with enhanced monitoring.
o Covid-19 positive and unwell will need community provision of nasal oxygen and pO2 monitoring with support and clear protocols for referral on to ICU if needed.
Making this all happen will require a radical step up in service planning and delivery, with serious system leadership and funding.
Homeless rough sleepers and Coronavirus (COVID-19)
COVID-19 is an evolving situation. Government advice(1) is to call 111 and follow Public Health advice for any suspected cases or contacts.
If a case is suspected, Public Health(2) will advise on testing and isolation.
People who are unhoused are more at risk when a public health or natural disaster emergency occurs.
The spread of communicable disease can be swift for people without adequate access to hygiene facilities or a safe home.
Pathway is aware, from UK Public Health authorities, that the current outbreak of COVID-19 spreads in much the same way as flu – through person to person contact; especially through droplets in the air produced when an infected person coughs or sneezes. The disease can be spread by touching an object that has been infected and then touching your nose, mouth, or eyes. It is believed people are most contagious when exhibiting symptoms.
- Shortness of breath
Symptoms of COVID-19 may appear in as few as 2 days or as long as 14 days after exposure.
Pathway recommends everyday actions to help prevent the spread of respiratory diseases, including:
- Avoid close contact with people who are sick.
- Avoid touching your eyes, nose, and mouth.
- Cover your cough or sneeze with a tissue, then throw the tissue in the bin.
- Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe.
- Wash your hands often with soap and water for at least 20 seconds, especially after going to the toilet; before eating; and after blowing your nose, coughing, or sneezing.
- If soap and water are not readily available, use an alcohol-based hand sanitiser with at least 60% alcohol. Always wash hands with soap and water if hands are visibly dirty.
- If a homeless hostel user does get diagnosed with COVID-19 we would advise making sure the public health team are well informed about the hostel set up so they can make appropriate provision for isolation and recommendations to protect others.
- Facemasks are crucial for health workers or people who are taking care of someone in close settings suspected of having COVID-19 (at home or in a health care facility).
IF YOU ARE:
- Experiencing symptoms – call 111 and follow the advice given.
- An outreach worker or concerned member of the public, consider stocking up on bottles of hand sanitiseror wipes to give to rough sleepers.
|If spread occurs, Pathway calls on the government to ensure there are adequate contingency plans in place, specifically for homeless people sleeping rough and people housed in hostels, that can be rapidly acted upon. Local authorities will need to provide quarantine accommodation as well as adequate support and advice. Reiterating transmission advice and initiating extra cleaning, and distribution of hand sanitisers to protect others could also become necessary. This would need to be adequately coordinated and funded.|
1 Coronavirus (COVID-19): UK Government response, https://www.gov.uk/government/topical-events/coronavirus-covid-19-uk-government-response
2 NHS UK Chief Medical Officers Public Health Advice, https://www.nhs.uk/conditions/coronavirus-covid-19/
These articles are timely, as last year the BMA declared the homelessness crisis a ‘public health emergency’ at its annual representative meeting in June.
The Doctor talked to Pathway clinicians in London, Manchester and Sussex, and made visits to the Royal London Hospital and Brighton teams, witnessing homeless healthcare in action.
“A hospital admission is an amazing opportunity. Someone is in a place where you can help them and where they may want help also. It can be an opportunity to break the cycle” said Dr Peter Buchman.
The third edition of The Faculty for Homeless and Inclusion Health Standards for Commissioners and Service Providers has been launched at a meeting of health leaders in central London.
The document sets out the health challenges experienced by marginalised groups such as people who are homeless, people who well sex, people from gypsy and traveller communities, and vulnerable migrants. It calls for the incorporation of values such as compassion and continuity of care to support integrated collaborative systems that improve patient outcomes.
The document has been endorsed by 14 medical Royal Colleges and health bodies, including the RCP, RCGP and RCPsych.
This unprecedented level of support demonstrates positive action towards the commitment made by the Academy of Medical Royal Colleges (A0MRC). In 2017 the AoMRC made a joint statement with The Faculty for Homeless and Inclusion Health pledging that medical Royal Colleges would support patients to improve their health, not only through medical treatment, but by providing advocacy, inter-professional working and engagement with public health.
Professor Dame Jane Dacre, past President of the Royal College of Physicians, said:
“Addressing the social determinants of health is an essential component of effective health care. New ‘duties to refer’ imposed by the Homelessness Reduction Act 2017 present a real opportunity for secondary care to contribute to integrated care, these standards explain clearly how to do this well.”
The launched, attended by 70 delegates included presentations and discussion from Professor Dame Jane Dacre, Dr Nigel Hewett OBE, Jon Sparkes CEO of Crisis, and Mo Elmi, an ‘Expert by Experience’ who uses his experiences of homelessness and health issues to train medical professionals.
Pathway were recently awarded a 15-month leadership grant from the Burdett Trust for Nursing to identify, network and support all nurses working across the UK in the emerging discipline of homeless hospital discharge.
Homeless hospital discharge nurses work in partnership with patients experiencing homelessness to achieve timely, holistic and compassionate assessment, treatment and discharge plans that improve health and housing outcomes.
Most of these nurses work in hospitals, although in many cases this is an in-reach intervention from community-based services. Some nurses work in Pathway teams, but many others do not. A small number of nurses that work to achieve better discharges for people experiencing homelessness are entirely based in the community.
The first clear reference to homeless hospital discharge practice was in 2003. A Department of Health document ‘Discharge from hospital: pathway, process and practice’ stated that all acute hospitals should have formal admission and discharge policies to ensure that homeless people are identified on admission, and that the discharge of homeless people should be notified to relevant primary health care and homelessness services.
Fast forward to 2019, and there are now around 25-30 specialist nurses in the UK directly involved in homeless hospital discharge (nearly all of whom have been involved in this project), and the NHS Long Term plan cited homeless hospital discharge teams (in this case a Pathway model team) as an example of good practice to reduce health inequalities.
Additionally, since October 2018, the Homelessness Reduction Act (2017) has now conveyed a ‘duty to refer’ on Accident and Emergency departments and inpatient settings for patients identified as experiencing homelessness, or being at risk of homelessness within the next 56 days. This requires patients to be referred to a Local Authority for support (with their consent). The hope is to focus acute hospitals on their responsibilities for safe discharge in this group. It may also result in the recruitment of more nurses into specialist roles.
Our Burdett funded project has revealed that homeless hospital discharge nurses need to be experts in clinical advocacy, patient empowerment, motivational interviewing, and health and housing rights. In addition, they need a broad clinical background in physical health, mental health and addictions and a good understanding of public health, and the concept of ‘making every contact count’, as well as an ability to gradually chip away to deliver systemic culture change. Having said that, to a large extent best practice has been developed locally by expert practitioners ‘doing the job’, and the evidence base is still limited.
Through shadowing and observation, interviews, and group workshops, the project has attempted to define the homeless hospital discharge nurse role clearly, including providing a breakdown of the knowledge, skills and experience required for the role with specimen job descriptions. An early vision for best practice has been defined, and local innovations have been highlighted. Continuing professional development needs have been analysed, and voluntary standards for practice are being developed.
Finally, and perhaps most importantly the project has helped the nurses to develop a shared vision of quality, and has defined this in terms of the value of a safe, effective and compassionate discharge, rather than by cost reduction per se (although the need to deliver efficiency has been taken into account).
The short report can be found here. The full report and resources developed on the project will be published and shared soon.
The Royal London Pathway team, who support homeless people in Tower Hamlets to live healthier, better lives, has today been awarded a top accolade in the prestigious NHS Parliamentary Awards.
Led by GP Dr Peter Buchman, the Pathway team has beaten the rest of the country to pick up the acclaimed Excellence in Urgent and Emergency Care Award.
Working at The Royal London Hospital and East London NHS Foundation Trust, the team were rewarded for their tireless work improving care for vulnerable homeless people.
The NHS Parliamentary Awards sees the NHS and MPs join forces to honour some of the biggest achievements in health and social care from across the country.
Dr Peter Buchman said:
“We are absolutely delighted to win this national award. People who are homeless often have complex needs, so they can require support from multiple agencies. We work in partnership with health, social care, legal and housing professionals to really help patients get onto a better pathway in life. Thank you for recognising the work of our small dedicated team.”
Jim Fitzpatrick MP, who represents Poplar and Limehouse, nominated the team. He said:
“I am absolutely delighted that the Pathway Homeless Team are the national winners in the NHS Parliamentary Awards. This is well-deserved and a great example of joint working between ELFT, Barts Health and the Clinical Commissioning Group to truly support homeless people who are among the most vulnerable in Tower Hamlets. Congratulations to everyone involved.”
The Pathway Team are based at The Royal London Hospital and has the ultimate aim of ensuring homeless people cared for by the hospital do not get discharged back to the street, but instead are found other options for housing, healthcare and ongoing support in the community. When an individual admitted to hospital is ready to leave, the team will work to arrange a smooth discharge to a safe place.
The team also encourage rough sleepers and people in temporary housing to register with a doctor at Health E1 Homeless Medical Centre in Brick Lane in Aldgate.
Simon Stevens, NHS England chief executive, said:
“It has once again been a privilege to celebrate with some of the extraordinarily dedicated and selfless health and care heroes who make the NHS what it is today – the much-loved institution that our patients say is what makes them most proud to be British.
“From those who have devoted their lives to helping people and supporting some of our most vulnerable, to delivering pioneering lifesaving treatments, the NHS Parliamentary awards are rightly honouring those who continue to make a huge contribution to our country, through our NHS Long Term Plan.”
The NHS parliamentary awards ceremony saw twelve winners honoured on Wednesday 10th July at the Palace of Westminster’s Terrace Pavilion, hosted by Dr Sara Kayat, NHS GP & TV Doctor.
Have you lived through homelessness, addiction, violence or abuse, sold sex or been involved in the criminal justice system? Or perhaps you are from a marginalised group, such as the gypsy and traveller community, or faced struggles after coming to the UK as a migrant or refugee. Most importantly, would you like the chance to take a free 6-week course at University College London (UCL)?
The Faculty for Homeless and Inclusion Health has helped UCL to compile a 15-unit course on health and social exclusion, that can be taken by itself, as CPD, or as part of the UCL Population Health MSc. The course includes:
- The health consequences of exclusion and practical responses
- Social theories of exclusion
- Women and inclusion health
- Quantitative and qualitative research methods
- Structural and legal factors
- Service development and evaluation
The course is open to medical professionals, social care practitioners, hostel and housing workers, researchers and commissioners, but UCL is offering two free places for ‘Experts by Experience’ (EbEs) – people like you, who have lived through social exclusion and have extra insights that have come from real life, not just books and study.
You don’t need to have previous qualifications, and you don’t have to tell other students on the course about your experiences if you don’t want to, but you will need to write a short statement explaining:
- why you should be given the ‘Experts by Experience’ rate
- why you want to study the course, and
- how it will further your career.
Please let us know if would like to apply, but cannot cover travel, food and stationery costs, and we’ll do our best to help.
Stan took the course as part of his role leading EbE inclusion for Pathway. He said:
“My education wasn’t the best, I left school with no formal qualifications. Taking part in the course was both challenging and rewarding. I was able to study as an equal for most part, but I got additional in good study practice and how to focus. The teachers ranged from acclaimed academics to people with lived experience of homelessness and exclusion. I’d recommend this course to anyone. If I can pass from a standing start then imagine what you can achieve.”
Bean took the course in 2018. He’d never studied at university level before. He passed and successfully applied for a new job as an outreach worker with an infectious diseases unit. He said:
“Doing this course had a direct impact on the type of work I do. It gave me the confidence to apply for a new job, which is a step up in my, admittedly late, career path. I would recommend it to everybody no matter what their job or interests.”
The Homeless People Teaching Dentists
Dentists will be the ones in the chair on Friday, when formerly homeless people take over as dental teachers at a special meeting in Birmingham.
‘Homeless and Inclusion Oral Health’, supported by Health Education England Dental Section, Pathway and The Faculty for Homeless and Inclusion Health Dental Subgroup will bring together nearly 150 young dentists, doctors, commissioners and formerly homeless people, to discuss helping vulnerable patients.
70% of homeless people have lost teeth since becoming homeless and almost all have tooth decay problems. Janine Doughty is a dentist and National Institute for Health Research (NIHR) Fellow who is chairing the event:
“Getting access to a dentist when you’re homeless can be hard. Tooth pain is pushing homeless people to desperate measures, like trying to pull out their own teeth. Nobody should suffer this way. Today will help dentists across the Midlands to develop skills to help the people who need it most”
Homeless health charity Pathway ran a pilot project, restoring smiles to homeless people. Stan Burridge was homeless for many years, he developed, managed and participated in the scheme, which he described as ‘life changing’.
“The biggest difference for me has been food. I had to cut it into small pieces that I could swallow whole, it’s embarrassing, and not being able to chew impacts on the taste. Now I have a full set of dentures. Having false teeth isn’t perfect, but as least I can enjoy eating, and I can chew most things.”
Stan will be presenting at the conference, presenting his work on supporting homeless people who are frightened of dentists. The day also includes sessions on helping people who have been sexually abused, and chance to meet former British Dental Association Chair, Janet Clarke MBE to discuss starting new services.
‘Homeless and Inclusion Oral Health’ takes place on 23 November 2018.