Primary Care is the first point of contact for most people with a health problem, but many people who are homeless struggle to access a GP.
Pathway, funded by the Healthy London Partnership, has produced a training video, slides and quiz, to introduce GP Receptionists to current regulatory guidance around homelessness.
‘My right to access healthcare’ cards
Being asked to provide proof of address and ID are a key barrier to them accessing primary health care in GP practices.
About ‘My right to access healthcare’ cards
The cards are designed to be carried by homeless adults. This includes people who:
- Sleep rough
- Live in hostels
- Sleep on family and friend’s sofas
- or who are chronically insecurely housed.
The cards can be used to remind GP receptionists and other practice staff of the National Patient Registration Guidance from NHS England.
It states that:
“people do not need a fixed address or identification to register or access treatment at GP practices where necessary, the practice can use its address to register the patient”
Working with homelessness (courtesy of Pathway)
Identifying and working with patients that are homeless
The receptionist should be the patient’s champion, ensuring that the system works to provide care, especially for the most vulnerable patients.
If someone reveals they are homeless at reception, try to help them access all of the healthcare they need.
If someone reveals they are homeless try to ensure that housing status is recorded on practice new patient forms, and then in the clinical record.
Encourage all clinicians to record and update housing status for all patients routinely.
Avoid putting No Fixed Abode (‘NFA’) on records.
Ask for possible ‘care of’ addresses, and contact numbers. Ask if the person attends a day centre or other service regularly and take details of this if possible.
If available ask for support worker details (and consider adding this field to practice new patient forms).
Always ask for next of kin details, but remember this may be a sensitive question if the person has lost touch with their family or ask them if there is a friend or support worker who could be contacted in an emergency.
Try to signpost them to relevant services (see further advice on signposting below).
Offer all new registrants a chance to have initial conversations away from the reception area in order to maximise confidentiality and alleviate any potential anxiety or embarrassment.
If your practice policy is to ask for identity documents, remember this is not a regulatory requirement and you should NOT refuse to register someone because they do not have them.
If a patient has a good reason for not having ID or other documents, register them anyway, and ask them if they can bring evidence in if and when they are available.
Ideally, practice leaflets should NOT specify the documents requested for registration at your practice. If this cannot be removed you could add a qualifying statement e.g. ‘If you are unable to provide these documents please talk to our reception staff’.
If you do need to refuse registration e.g. because your practice list is closed, or the patient lives outside your catchment area, discuss this with your manager before taking action. You must record details of this refusal, and your practice must write to the patient within 14 days to explain why. If the patient is homeless you will need to ask where this letter should be sent (or offer to have it available for pick up). Records of refusal should include name, age and ethnicity details of the patient, and a record of the letter sent.
If your practice routinely gives out appointments on the day by phone only, check whether new registrants have access to a phone. If the answer is no discuss with the patient how they will be able to book appointments, including on-line options.
Routinely offer patients with addictions, mental health problems, cognitive difficulties and/or multiple problems longer appointment times. Consider putting an alert on the record reminding all practice staff to consider this when booking appointments.
Routinely give patients appointment cards, and consider providing telephone or text reminders for appointments if this is possible.
Consider operating appointment flexibility for those with difficulty keeping appointments. Again, consider putting an alert on records indicating that flexibility may be needed.
Promote online access to summary medical records as this may be particularly beneficial for homeless people e.g. for booking appointments or ordering repeat prescriptions in the case where they may not have credit on their phone, but do have access to the internet at a day centre or library.
If a patient who is homeless has let you know they have a support worker, discuss with them whether they want you to inform the support worker or others about upcoming appointments or referrals.
Inform patients that they are welcome to bring support workers with them to appointments. This is likely to be helpful to help the patient remember the details of the appointment.
If your practice is in an area with a peer advocacy contract, consider whether the patient would benefit from peer advocacy support, and offer to refer them.
Ask about any special needs / issues that may stop patient accessing care e.g. if the patient has a dog they do not want to leave, or has to attend addictions services every morning – consider putting alert on the records regarding these.
Language and communication needs
Offer a chance to have initial conversations away from main reception area to maximise confidentiality and evaluate any additional communication needs the patient might have.
If any additional communication support is needed such as interpreting (including British Sign Language), take steps to arrange this as you would with patients who are not homeless.
On-line or telephone interpreting can be used at registration, but for follow-up, interpreters should be booked.
Friends and family members should only be used to interpret in very exceptional circumstances. Take advice from a senior member of practice staff if a patient requests this. The use of family and friends as interpreters should not be encouraged; they should be the last resort. Their presence could inhibit information disclosure or generate embarrassment and can also be difficult for the family or friend, especially if children are interpreting.
Record language and communication needs on registration forms, and in clinical notes.
Offer ‘Your Guide to the NHS’ in a language that is relevant to the patient.
Book a 20 minute appointment for first appointment, and offer to book interpreter for the appointment.
Your practice leaflets should already comply with the NHS’s Accessible Information Standards (www.england.nhs.uk/ourwork/accessibleinfo)
Ensure all practice leaflets are written in simple language, and a simple font (e.g. Arial) of at least 12 point, preferably 14. Further tips are available on page 16 of the Accessible Information Standard Implementation Guidance.
When giving out registration / other forms always ask if patient needs help filling in forms. Be prepared to offer assistance if required.
Ensure practice meets standards set out in the Equality Act 2010 and Health and Social Care Act 2012. This means ensuring that that all patients are treated equally in terms of access and treatment with regard to race, ethnicity, gender, age, religion/belief, disability, sexual orientation, and socioeconomic inequality – as your practice needs to be able to evidence that you do this.
This may mean undertaking an equality assessment at your practice, and considering whether any changes need to be made. Discuss with your practice manager whether this is needed, and how you can help.
Cultural competence is the ability to provide care to patients with diverse values, beliefs, and behaviours, and tailoring healthcare delivery to meet patients’ social, cultural and linguistic needs. It is important for all staff in the NHS to understand the cultural needs of patients and provide health care in a way that respects this.
Familiarise yourself with common cultural practices for your practice population, and develop practice protocols to accommodate these.
Record preference of gender of clinician for all patients (or no preference, if no preference).
Ensure practice considers women’s and men’s health issues in new patient checks.
Ensure leaflets are available for victims of gender based violence.
Use the word partner when asking about the existence of close personal relationships.
Familiarise yourself with common cultural practices for your practice population which relate specifically to gender, and develop practice protocols to accommodate these.
Ensure new patient checks ask patients who are homeless if they would like to have any disabilities recorded in their record.
A practice should undertake regular audits to ensure that the needs of patients with disabilities have been met within the practice – discuss with your practice manager whether this is being achieved, and how you can help.
Signposting patients appropriately
Ensure you can find relevant websites easily. Perhaps they could be put as shortcuts on your desktop, links on your practice website, or as bookmarks in your browser.
At the minimum this should include:
Have leaflets available at reception which provide information about a) local authority homelessness advice services b) key voluntary sector services for people who are homeless c) Citizens Advice d) addictions services
Shelter (www.shelter.org.uk) You may also wish to give out the Shelter website or helpline number (0808 800 4444) for advice on complicated housing issues, particularly if a patient says they have already sought help from your Local Authority homelessness advice services, but have been unsuccessful.