The advice in this article originally appeared in the Welsh Pharmacy Review, the Scottish Pharmacy Review and the Northern Ireland Pharmacy Review in 2017. It was written to help pharmacists understand how their work can help patients who are homeless. Please feel free to use this in your teaching, click here to download a copy.
What does home mean to you?
Imagine a world where you have nowhere to rest, wash or eat. Where you have lost touch with the people you love, and have no idea where you’ll sleep that night. It’s a frightening, lonely, unhealthy existence, but for many people it’s a reality. An increasing number of people are becoming homeless because of rising rents, redundancies, or benefit changes. Government statistics show that last year
- 59,250 people or households were accepted as homeless in England
- 18,628 people presented themselves as homeless in Northern Ireland
- 34,662 people made homelessness applications in Scotland
- 7,128 households were assessed as ‘threatened with homelessness’ in Wales
Some will be sleeping on the streets, many more will be ‘hidden homeless’: sleeping on a friend’s sofa, on buses, moving between night shelters, or exchanging sex for somewhere to sleep. Many have physical or mental health problems or a dependency on drugs or alcohol, often those who do not will develop problems when faced with life on the streets. Our home is important to our sense of safety. People without a home are 9 times more likely to take their own life, and have high rates of depression and anxiety. Homelessness is also bad for physical health and homeless people are more likely to have asthma, heart disease, hepatitis C or tuberculosis.
As a pharmacist, what can you do for homeless patients?
Healthcare and prescribing may seem a world away from the person sleeping under a blanket in the doorway, or a family crammed into a bed and breakfast room; but you can play a key role in helping homeless people recover.
In England, patients are charged for medication, even patients on some benefits. A 3 month prescription may reduce costs for them, but remember patients may struggle to store medication or keep it dry. Some hostels restrict medications for legal reasons or because they fear it may be stolen to sell (and this is not always the most obvious drugs).
Free prescriptions in Scotland, Northern Ireland and Wales have radically changed the prescribing landscape. Dr Richard Lowrie, Pharmacist at the homeless health service in Glasgow says
‘Depending on the medicine, I write a month-long prescription to be dispensed weekly. It reduces the amount that is lost or wasted, and it means that I can monitor patients as they adapt to new medicines. It helps the patient to build trust through regular engagement with the community pharmacist. Conversely some patients engage better if given the whole month supply – it shows that we trust them to manage’
Take time to explain
A St Mungo’s report found that over 50% of homeless people have literacy problems, so it’s vital that verbal information is given as well as leaflets.
Take time to explain things and work with the patient. Not everyone can predict when they will have access to food, so ‘take it before breakfast’ might not be helpful. Ask what is routine for that person, would arriving at a day centre be a better reminder?
Kate Robinson, a Drug and Alcohol Nurse at a central London teaching hospital, believes educating patients improves concordance:
‘Patients who are withdrawing from heroin often don’t understand the reasons for Methadone dose titration. I explain the long half life of Methadone, and that an effective dose will be achieved over time. Unless the patient knows that they are being heard, there is a risk that they’ll self discharge to seek heroin, abandoning vital medical treatment. It’s much harder for us to get back in touch with a homeless patient.’
A few words of explanation from a pharmacist could literally be the difference between life and death.
The method of medication delivery is also important. Specialist Nurse Sam Dorney-Smith advises checking whether patients can open bottles, or dispense from blister packs. She describes achieving great results simply by changing to breath-activated inhalers for those with co-ordination problems.
Dosetting is seen as an expensive last resort, but it can increase concordance in patients who are struggling, potentially avoiding a costly inpatient stay. Alternatively, slow release, once-a-day versions of medications may help.
Sam also talks passionately about the need for patients being prescribed injectables to be assessed, urging professionals not to assume that patients who have injected street drugs, can safely inject insulin or Clexane for example.
Pharmacies offering on-site dispensing may wish to consider linking with needle exchange services.
Even ‘safe’ methods of delivery might not be so safe. One hospital pharmacy was asked not to dispense certain brands of painkilling patch after finding out the active ingredient could be removed and injected. Drug dealers were targeting patients, leaving them without medication. Local knowledge is invaluable, so talk to patients and local teams.
Homeless people on the street are often ignored. One man described feeling ‘invisible, less than human’. Then suddenly patients beginning to engage with services are bombarded with an overwhelming number of staff as they move between night shelters, hostels, temporary accommodation and flats.
A constant relationship with a healthcare worker, within professional boundaries, can help to counter those changes, take time to chat if you can.
Your work will be most successful if you ask your patient’s permission to work with everyone involved in their care. That might mean letting support workers know about potential side effects or notifying prescribers if a person stops collecting medication (especially if this is a warning sign that a mental health problem or substance misuse issue may have recurred). Support workers can also work alongside pharmacists to help patients move from dosetting to self-administration.
Helping the wider homeless community
Medication storage and management is a huge problem for many homeless hostels, and many patients haven’t had medication reviews. Getting to know local hostel workers can reap considerable rewards.
Pharmacies can help by carrying leaflets for local housing support services to help patients. These also signal that you will not act pejoratively towards homeless patients.
What you can do as a… Community Pharmacist
Community pharmacists dispensing medicines to aid in the treatment of opiate addiction have a unique opportunity to have daily contact with these patients, and an opportunity to build a relationship. This provides a chance for ongoing monitoring of mood and health conditions, and a potential avenue into health screenings.
Successful trials of pharmacy-based hepatitis / HIV screening have identified that many ‘at-risk’ patients prefer walk-in services and feel more comfortable being screened and receiving anti-retrovirals at a pharmacy.
Specialist Homelessness Nurse Sam Dorney-Smith says that pharmacists can really help with smoking cessation:
‘This aspect of care is often wrongly ignored for homeless patients, but with incredibly high levels of COPD amongst the target population it’s vital that support is offered.’
What you can do as a… Hospital Pharmacist
Timely TTAs can make the difference between a person getting housing, or sleeping on the street after leaving hospital. How?
Approaching a local council for housing often means queueing early in the morning, as many use a ‘first come, first serve’ system.
Having TTAs ready first thing in the morning helps workers ensure a patient will be seen. Most homeless patients don’t have the money to come back to hospital later, so it’s vital they’re ready.
If patients with opiate dependency are being released on a Friday consider whether you can offer a weekend methadone prescription. Your short-term support could be the difference between a person engaging with support services or reverting to using street drugs because they cannot cope with the impact of hospital release, opiate withdrawal and housing relocation all in one day.
Out there and doing it
Alison Hair and Richard Lowrie began working in homelessness after realising there were gaps in mainstream NHS pharmaceutical services. Today they are based at Hunter Street Homeless Service, Parkhead Health Centre and hostels across Glasgow, providing weekly sessions in a multidisciplinary team. Half day clinics usually involve 5 or 6 patients, focussing on the management of chronic diseases. Independent prescribing has improved the efficiency of the clinics, and the pharmacists work closely with other specialists in the team.
Kate Robinson is a Drug and Alcohol Nurse at University College London Hospital. She provides assessment and treatment planning for patients with drug and alcohol issues, patient advocacy, liaison with existing treatment providers, and referral to follow up care. Many of her patients are homeless, or at risk of losing their homes. In addition to her patient work she gives guidance to clinicians on prescribing and management for patients using drugs or alcohol, through formal training and point of care advice.
Samantha Dorney-Smith is a Pathway Nursing Fellow. She is a Nurse Prescriber and previously managed a specialist community nursing team providing outreach to homeless hostels and day centres in London. She was the founder of the UK’s largest and busiest homeless health team, Pathway King’s Health Partners and a member of the Faculty of Homeless and Inclusion Health working group examining safe medication dispensing in homeless hostels.