Relocating patients from a specialist homeless healthcare centre to general practices: a multi-perspective study

Demographics

Patients (n = 17) were aged 30–48 years (mean = 40.3, standard deviation = 5.4) and most were male, had experienced homelessness for more than 1 year, and described their general health as ‘fair’ (Table 1). Nineteen staff participants were recruited. They were aged 27–65 years old, with most being female administrative members of staff (Table 2). Qualitative findings are presented in relation to themes within the 10 TDF domains identified in the analysis. Four TDF domains were not identified in the analysis: goals; behavioural regulation; optimism; and memory, attention, and decision processes.

Beliefs about consequences

Staff (in an effort to maintain anonymity staff regardless of profession are hereby referred to as staff after quotations) and patients described several consequences of relocation, which they perceived as barriers. Themes were identified relating to patient concern over continuation of their ongoing healthcare needs on relocation; apprehension about meeting new staff at mainstream practices; ability to integrate; and perceptions of mainstream practice.

For example, one patient noted their concern regarding the establishment of new relationships at mainstream practices and potential stigma: ‘Obviously, you’ve got a little concern that you’re going to get on with your doctor and you’re going to like your doctor and they’re going to, like, take to you and not look their nose down to you because of your past and stuff.’(Patient 1, female, age 40 years, mainstream practice)

This was further emphasised by a staff participant: A lot of them feel if they go to a mainstream surgery they’re classed as a, they’re treated as a second class citizen.’(Staff 9, pharmacy)

Intentions

Patient intentions were described by staff and patients as key to relocation. Themes included intentions to relocate and reluctance to relocate. While some patients initiated the relocation process themselves, others expressed a reluctance to relocate. Factors affecting intentions included ongoing treatment and the negative experiences of others who had previously moved.

As noted by one staff participant, some patients were reluctant to relocate: ‘A number of people who I suppose I’ve worked with over a period of time would probably rather just stay there because they know it and it’s, you know, the people and it is probably a hassle to have to go and find a GP practice and go along and fill in forms and do it all.’(Staff 7, mainstream practice)

One patient stated that they felt that they would not move because of the experience of others: ‘In my personal opinion I wouldn’t move after what I’ve seen over the last 6 months of somebody moving from here to somewhere else. It’s just an absolute joke and I just [feel] that [is] pathetic.’(Patient 7, no demographic data available, SHHC)

Environmental context and resources

Staff and patients discussed the impact of environmental context and resources on relocation and integration. Key themes included lack of effective means to establish a patient’s housing status (although patient eligibility for relocation was also considered in terms of clinical stability); SHHC resources in communicating and assisting people to relocate; communication between SHHC and mainstream practice; diverse policies and operating rules in mainstream practices in registering patients such as photographic identification requirements; a patient’s access to resources, for example a telephone; and a lack of continuity of services such as podiatry and dentistry at mainstream practices after relocation.

A staff participant at the SHHC explained how continuity of services to mainstream practices could prove problematic: ‘Other care, dental services here, no longer homeless they wouldn’t be able to access that, they would need to go and register elsewhere. Podiatry services that we’ve got here they wouldn’t, they just would be unlikely to access that ‘cause the services are not available for straightforward foot care.’(Staff 5, SHHC)

Further, one patient, described how the SHHC offered a level of specialised care which was unparalleled: ‘Just the underlying issues that I have at the moment that I don’t feel they can facilitate the best way as what this practice [SHHC] can, for me, at the moment.’(Patient 12, female, age 30 years, SHHC)

Knowledge

Themes identified by staff and patients included patients’ knowledge of administrative processes involved in relocation; an awareness of eligibility for relocation; knowledge of mainstream practices in their local area; and a lack of knowledge of the rules and policies of mainstream practices, as well as knowledge and experience of SHHC staff in managing homeless and formerly homeless patients.

One staff participant underscored how it may be beneficial for patients relocating to be made aware of the regulations and policies of mainstream practices: ‘I think they need to have a bit of learning before they leave SHC to say that, I mean, I’ve worked at SHC so I understand that, I know what happens with them, they don’t turn up for their appointment in the morning but they get their script in the afternoon, there’s not a GP there. It’s, appears quite easy to do that but they have to understand when they’re at a practice like us we’re nae going to do that.’(Staff 1, mainstream practice)

Skills

The importance of patient skills was identified in relation to a theme regarding integrating and adapting to the culture of mainstream practices. One patient experienced little difficulty in integrating: ‘Yeah, I’ve just been twice since I moved and everything’s been okay, transferred nae problem at all.’(Patient 3, male, mainstream practice)

However, it was suggested that some patients may experience issues integrating into mainstream practices: ‘We do find them [relocated patients] challenging people to, to try and integrate into our way of working, shall we say.’(Staff 2, mainstream practice)

Social and professional role and identity

Both patients and staff identified the influence of social and professional roles and identities in relocation.

Themes included patients self-identifying as homeless and expectation of negative perceptions; patients not perceiving the SHHC as a specialist practice for those experiencing homelessness; changing healthcare/lifestyle needs of patients serving as a prompt to relocation; the role of staff at the SHHC in facilitating relocation; and the ability of pharmacy staff to assist in the relocation process.

One pharmacist described their potential role in the relocation process: ‘Because we see these patients everyday we’re obviously in a very good position to be able to speak to them, we’ve got good relationships with them so we could use those relationships to be able to support them and find out more information about their movement from one practice to another.’(Staff 1, pharmacy)

From a patient’s perspective, staff at the SHHC can have a positive role in facilitating relocation: ‘She [staff member at SHHC] would always be like “have you found another practice? If you need any help, if you go up and they’re like, ‘we’re not taking anybody else’, phone me and I’ll speak to them if you want”.’(Patient 3, male, mainstream practice)

Beliefs about capabilities

Staff and patients described a key theme relating to self and patient’s perceived ability to integrate into mainstream practice. Self-esteem and confidence were regarded as critical concepts impacting a person’s ability to integrate. A staff participant discussed the ability of patients to integrate particularly in terms of building confidence: ‘I think the self-esteem and the confidence and, you know, kind of that element of it takes so much longer to build back up in the person.’(Staff 1, SHHC)

Social influences

Both staff and patients identified the impact of social influences on relocation. The principal themes identified illustrated the influence of health and social care professionals, administrative staff, and family and friends in promoting relocation, and the experiences and influences of patients who had relocated previously.

For example, the experiences of others who had previously relocated both positively and negatively influenced an individual’s willingness to relocate and the practice that was selected for relocation: ‘ [Patient’s] been cut off heaps of stuff [services post-relocation] in the space of 6 month and just completely a joke … so, in my point of view, moving practice, just with personal experience with somebody that I ken I just, I wouldn’t be happy about moving set up like.’(Patient 6, male, age 34 years, SHHC)

This theme was further emphasised by a staff participant: ‘Maybe they hae friends that are here [mainstream practice] and thinking “well, I’ll just, I’ll just go”.’(Staff 1, mainstream practice)

Reinforcement

Reinforcement was discussed by staff and one patient primarily in the context of healthcare professionals, administrative staff, social care workers, and family and friends who were perceived as important in facilitating and reinforcing relocation.

It was highlighted that staff often discussed the benefits of relocation, such as a greater availability of appointments at mainstream practices, in an effort to incentivise and motivate eligible patients: ‘We always try to portray the positive, you know, “this is you moving on, the range of services, the timescales, you know GPs to choose from, you choose your own GP, you could get a late appointment after your work or before you work”.’(Staff 4, SHHC)

One patient explained how patients were unlikely to relocate unless staff at the SHHC reinforced it: ‘No, just, just, the only way people are going to move is if somebody sits down and does it for them, and that’s real, that’s realistically the truth isn’t it?’(Patient 1, female, age 40 years, mainstream practice)

Emotion

Emotion was identified by staff and patients as influential in the decision to relocate. Themes identified were patient expression of emotions in relation to relocation and emotional attachment to the SHHC.

For example, an individual’s emotional attachment to the SHHC often presented as a barrier to relocation. This was mentioned by staff: ‘I guess the fact that if you had been seeing one doctor for a long time and then all of a sudden you need to go to somewhere different everyone would kind of feel that initial anxiety but I’ve never had anybody saying continuing problems they’ve experienced at a new practice.’(Staff 8, pharmacy)

Patient participants also noted emotional attachment as a barrier to relocation: ‘I’d be very, very upset if I was asked to leave.’(Patient 10, male, age 45 years, SHHC)