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The forgotten community

23 October 2015

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Not having a roof over your head can be a traumatic experience and the homeless often overlook their health matters. St Werburgh’s Medical Practice for the Homeless gives its sole attention to those without a fixed abode 

Winter is coming, and while many of us can snuggle up at home on those cold dark nights there are others who aren’t so fortunate.
As homelessness is on the rise it has become a challenge that is proving harder to tackle. Homeless charity Crisis estimates that the number of rough sleepers has risen by 37% from 2010 to 2013 but this has stalled to 5% in the last two years. However, while many assume that the homeless population covers rough sleeping there is in fact a wide definition.
According to Crisis there are several categories: rough sleeping, statutory homeless, hidden homeless, squatting and hostel accommodation.
Crisis estimates that around 185,000 people experience some form of homelessness each year in England.
Healthcare for the homeless population is often overlooked. Typically, GPs and nurses take part in outreach programmes and go into homeless shelters and day centres to treat those without a fixed abode.
In Chester, however, St Werburgh’s Medical Practice for the Homeless is a general practice that only accepts homeless patients on its books.
Given its 12-year history it’s no surprise that it has become so well known in the area.
It was originally set up by the primary care trust (PCT) and its first GP was Dr Martin Dennis. Skip forward to 2011 and PCT days were numbered and they no longer managed general practices. This meant St Werburgh’s came up for tender and had several practices bidding to take it over.
Northgate Medical Centre won the prize on 1 April 2011 and its practice manager – Gary Howorth – took on St Werburgh’s and manages it remotely. Howorth says: “We [Northgate] are only 50 yards away and we already had a relationship with St Werburgh’s. We did telephone consultations outside of its core hours, 8:30am till 5:00pm – there are no extended hours at St Werburgh’s.”
This unique practice is small and its patient list is minute, only 350 in comparison to its sister practice that has 7,000 people on the books.
St Werburgh’s has two part-time salaried GPs working 16 hours a week each, three admin staff that double up as secretaries and receptionists, a counsellor and last but not least, Pauline Finlay, Queen’s Nursing Institute specialist nurse practitioner for the homeless.
With few people on the register, staff at St Werburgh’s know most of each patient’s case history, which is essential given the challenges faced with such a varied patient list.
There is no one reason as to why someone becomes homeless as Howorth points out. He says: “There is a high proportion where the problems stem from childhood. A lot of child abuse results in them going off the rails.
“Also, we have just gone through a recession and there are your ‘middle class homeless’ shall we say. I’ll use the example of a male that looses his job, his house, relationship and finds that he’s affectively surfing sofas at friends’ houses and that’s the classic homeless that we are seeing nowadays. Quite frightening!”
The affects of homelessness and in some cases a traumatic childhood can often result in mental health issues developing as an adult.
With such harrowing stories it is understandable that there have been some cases of aggression boiling over into verbal abuse of staff at St Werburgh’s, according to Howorth.
Unfortunately, a case 12 months ago was deemed too dangerous to put the staff’s safety at risk any longer and a security guard was appointed and paid for by NHS England.
The incident in question involved a patient who knocked a door down to try and get to one of the clinicians who hadn’t prescribed him what he wanted.
“In the four years I’ve been managing Werburgh’s that’s the only major incident that we’ve had,” says Howorth.
The practice does have panic buttons that link with security in Chester but Howorth insists that the staff don’t want the police to visit frequently. It is feared the patients won’t go in as it’s in “the nature of the people that go to the practice to have a reluctance and resistance to the police”.
The environment is pitched at a casual level to try and maintain a relaxed feeling, which is why the staff generally wear casual clothes.
“We don’t want any sort of authority, the doctors and Pauline are respected generally,” he says.
Although there are several categories of homelessness where individual’s stories can be worlds apart, many suffer with mental health issues. It’s no surprise that the counselling service is incredibly popular at St Werburgh’s.
Before Howorth started there used to be a full-time counsellor but it has now been cut down to one day a week.
“The powers that be in the mental health team centrally have gradually pulled the hours from the practice and said, ‘actually we need you to be doing other things’,” says Howorth.
St Werburgh’s has been able to fill this void by utilising one if its receptionist’s skills as a counsellor two days a week. Having done private counselling before starting at Werburgh’s, Bill Bytheway-Jackson is able to do both jobs, which is “good for the patients as they can actually see him when they come into reception as well”.
Mental health is one issue that the practice faces every day. It also treats patients with respiratory, leg and skin problems. The medical staff do a “cracking job. These patients might only come in once or twice – it’s a one stop shop. The staff have got to know everything”.
Follow up appointments are encouraged and while some patients are good at returning many do not. But as Howorth points out it can be the same with ‘normal’ general practice as well.
The daily routine at St Werburgh’s is different from most practices. Generally, it is quiet between nine and 10:30am and rather unusually the practice has some patients visiting without an appointment, fall asleep in the waiting room and having to be asked to leave.
“The admin staff also get those folks coming in who hang over the counter talking about this, that and the other,” Howorth explains.
The team at St Werburgh’s go above and beyond their work remit. “In the past the staff have given out clean socks and washed people’s feet.
“Pauline [the nurse practitioner] has taken people up to the local hospital to make sure they get to the right place,” says Howorth.
The clinicians at St Werburgh’s also visit a homeless centre and give check ups. Howorth explains: “Even though the fact is that it’s a specific practice for the homeless some people are still reluctant to go because they might see it as a place of authority.”
Understandably the practice works closely with the community. It’s in a prime position to offer advice to patients on the next steps to gaining shelter.
While St Werburgh’s has 350 people on its list, Chester council states that at the moment there are only 47 homeless people in Chester city. The difference stems from the fact that not every person may fall into Chester council’s category of homeless. Therefore, not every person that is homeless falls under the requirements to be given accommodation.
Given such a vast difference between St Werburgh’s patient list and Chester council’s figures, St Werburgh’s is well placed to be the eyes and ears for such an ostracised and hard to reach community.
The practice is in a position where it can offer help other than healthcare to these patients. “We’re quite closely involved with the local council, which then spreads down to the various voluntary sector companies, housing, etc and we try and put people in touch to [get the right help]. Helping people isn’t just about the medical side it’s about the social as well.”
While all staff have a wider understanding of the local area it’s the receptionists that are often the ones best placed to offer advice. “All the staff help but it’s mainly the receptionist offering advice, the doctors and nurses might have some knowledge on how to help with non-medial related matters, but generally this is normally the conversation over the reception counter.”

The practice has become invaluable to the community, in particular the other local practices in Chester. St Werburgh’s is also the designated practice that takes on violent patients that aren’t homeless. It’s a challenge and there are currently 15 ‘violent’ patients on the books.
“I think it was thought it would be a good idea because it isolated [the patients] away from ‘normal’ general practice. The problems range from verbal abuse, to very bad verbal abuse to actually threatening behaviour. You can just imagine what’s in between.” The idea of the scheme is to help the patients back into their original practice.
For some, the intention is they will be on the potentially violent register for a 12-month period. Each case is agreed with NHS England locally, but the intention is after 12 months they are reviewed; regular meetings take place with the staff.
“After 12 months the intention is to try and get them back out onto the straight and narrow and back out into their normal practice. This has it’s own challenges as you can imagine trying to convince the other practices to take them back again. It’s interesting at times but it does work and we have sent quite a few back in my time managing it,” he says.
General practice is struggling, even those in affluent areas are facing difficulties. And the survival of St Werburgh’s isn’t set in stone. It very much depends on its sister practice taking a view on its success.
“We get a fixed amount of money per year to run the practice, which has actually just reduced because of the climate we are in. Obviously, Northgate Medical Centre (its partners) has to consider that it is viable as a proposition going forward, which would be a hell of a shame to loose it.
“At the end of the day my partners won’t be dipping into their own pockets to fund it. That will be up to [Western Cheshire Clinical Commissioning Group] and NHS England to do that.”
Northgate has the contract for another two years. He says: “We’ll have had six years by then. Fingers crossed it continues, not necessarily in it’s current format but whatever the powers that be decide.”