Morbidity trends in the population of a specialised homeless primary care service

INTRODUCTION

National economic analysis shows that homeless people are high users of unscheduled care, with five times the accident and emergency (A&E) attendances, 3.2 times the admissions, three times the duration of stay, and eight times the secondary care costs of the housed population. This is associated with an average age of death between 40 and 44 years.1 Canadian research shows a two in three chance of a 25-year-old Canadian male living to the age of 75 years, this is reduced to one in three among 25-year-old residents of shelters or rooming houses.2 A study of hospital admissions in Glasgow found that a homeless patient admitted with a drug-related problem was seven times more likely to die over the next 5 years than a housed patient admitted with the same drug-related diagnosis.3

The Cabinet Office Social Exclusion Task Force and the Department of Health have recently published a study called Inclusion Health, which aims to encourage the commissioning of services for socially excluded groups, such as homeless people.4 Over the years, specialist homeless primary care services have been developed in some areas to try and meet the particular healthcare needs of the homeless population, but there are few data available on the outcomes of these developments.

A full-time specialist primary healthcare service for homeless people in Leicester was set up in March 2000. This followed a needs assessment and research seeking the opinions of homeless people.5 Over 10 years, the service has grown to include a full team of nurses and GPs, with dedicated drug and alcohol workers, a sessional counsellor, aromatherapist, and optician, and a mental health team including community psychiatric nurses, a psychologist, and consultant sessions. Since 2006 the service has been provided from new one-stop shop premises, that include a drop-in centre run by the YMCA, which also serves as the practice waiting area, and a 42-bed shelter run by the local authority. A weekly multi-agency meeting coordinates care between front-line agencies for the hardest to reach of the homeless population.6 This report aims to compare diagnoses of attenders between 2003 and 2009.

METHOD

Annual reports are used to publish progress reports on the developing service, results of audits, and patient satisfaction surveys. A full morbidity survey of all computerised diagnoses did not alter significantly over the first few years so was last carried out in 2003. This survey was repeated in 2009 to look for any changes. The trends in infestation rates were particularly striking, so an additional annual analysis of recorded cases of head and body lice and scabies for each year from 2001 to 2009 was carried out.

RESULTS

The practice population stabilised within a year, at around 9000 annual consultations for 1000 patients. With a 59% annual patient turnover, the total number of different patients seen over the 9 years to March 2009 was 4407. Almost all patients are in the age range 17 to 64 years, and 15.8% are female. Fifty-three per cent of the practice patients were born in Leicester and another 33% elsewhere in the UK, so this is a service largely for a local population; 65% were unable to work due to long-term sickness and 74.7% reported a longstanding illness, disability, or infirmity.

The incidence of main diagnoses between 2003 and 2009 is shown in Table 1, while Figure 1 show changes in infestation rates over time. These encouraging trends are probably due to a combination of improved access to treatment, with reductions in rough sleeping and improved hostel conditions.

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Figure 1

Infestation rates over time.

DISCUSSION