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Realistic Medicine in action: the Glasgow PHOENIx

Realistic Medicine in action: the Glasgow PHOENIx (Pharmacist led Homeless outreach Engagement Nonmedical Independent prescribing (Rx) team  

A key principle of Realistic Medicine is, through properly talking with our patients, to ensure that we are not inadvertently 'overdoing' our investigation and treatment and risking providing burdensome treatment for minimal benefit.

Equally important is to be aware of potential inequalities in our systems. We are reaching out to our most vulnerable patients, who often struggle to access healthcare, but who really do need the care that we can provide. The PHOENIx team does just that. 

PHOENIx – the Pharmacist led Homeless outreach Engagement Nonmedical Independent prescribing (Rx) team – is an innovative approach from a team of NHS GGC pharmacists who are collaborating with the Simon Community (Scotland) and Marie Trust to provide ‘on the spot’ street health and social assessment and care for people who are experiencing homelessness in Glasgow. 

They have found that their engagement with this vulnerable group – who often have very significant health problems further complicating their lives - has been very well received by those that they are helping. Feedback from users suggests that this different, deliberately non-judgemental approach is much more meaningful to them and recognises their difficulties with attending conventional appointments. They feel at ease and listened to. And it is effective. 

Evidence is building that some people who were high users of emergency departments and frequently admitted, are now having their problems more holistically addressed and their dependence on hospitals has dramatically reduced as a result. By working in pairs (a pharmacist teamed with a Simon Community or Marie Trust link worker) they can also address social, housing and benefits issues. This appreciation of severe health inequalities whilst striving to personalise care is a superb example of Realistic Medicine in action in Glasgow and benefits both patients and the wider service. 

Why is this so important? 

People experiencing homelessness (PEH) are the most marginalised, destitute and vulnerable group in the UK. Although the majority are in their late 30s, the number of health problems are on a par with 85 year olds with homes. Most die by the age of 43 years (refs 1-4). 

People experiencing homelessness find it difficult to seek and obtain help in primary care often not doing so until it is too late. However, rates of Emergency Department (ED) / minor injuries presentations are about 20 times higher than in people living in their own homes: the primary health care system does not work as well for PEH. Most primary care health services are based on appointments or contact by phone; whereas PEH people have temporary accommodation at best, often no reliable access to a phone with credit and no means of travel to see their GP, community workers or specialised (often centralised) addictions, mental health, or hospital services. 

Despite having multiple and complex needs, health conditions are often underdiagnosed and undertreated, medicines adherence is low, clinic attendance low, and there is a tendency to drop out of care for a variety of reasons, many out with the PEH’s control. Previous or ongoing trauma is often contributory. PEH have disproportionately high rate of presentation and representation at ED and many use ED as first port of call for health problems.  

 

What does PHOENIx do? 

NHSGG&C Pharmacists’ response was to secure short term external funding to enable the setup of the PHOENIx team. They work in collaboration with Simon Community (Scotland) and Marie Trust link workers, with a base in Hunter Street Homelessness GP service. The team provide assertive outreach for the GP practice – offering ‘on the spot’ street assessment, treatment, prescribing, referral and advice to address issues. The ethos of the team is to provide first contact, continuous and comprehensive health and social care support until the patient is ready to re-engage with ‘building based’ primary care services. They aim to engage with people who are experiencing homelessness to improve their primary health care, housing, benefits and social integration in mainstream care, onwards to reducing ED attendance. They share primary care, secondary care and social care records.  

They work in pairs: an NHS Pharmacist is always teamed with a Simon Community Street worker/Marie Trust worker.  They ask the patient what is the most important part of their care to prioritise and help with addressing it, while working on other presenting problems. In addition to helping with healthcare, they assist with social, housing and benefits issues and where necessary can facilitate attendance at appointments and advocate for patients when required, trying as far as possible to minimise drop-out from services. 

How do you refer?

Referrals can be made by email ([email protected]) or by phone (07971827565). The team operate Monday to Friday 9 to 5pm and until 9pm on Thursdays and are contactable out of hours by phone or email. They attend Glasgow Royal Infirmary Emergency Department twice a week for referrals. Referrals are accepted for any patient presenting as homeless. The team’s input is for as long as the patient requires help, always updating the patient’s own GP, until the patient is ready to directly link with their own GP. The service acts as a critical bridge back into mainstream care. As independent prescribers, the pharmacists are able to prescribe medication. 

Does it work?

Work has been undertaken to evaluate the service (refs 5-17) and the team have asked patients to describe their experience of the service. Quantitative and qualitative findings are overwhelmingly positive. Many emphasised the positive influence that the friendly, informal and non-judgemental approach of staff had had on their willingness to engage. Furthermore, the extended time spent in consultations, which exceeded that experienced in formal healthcare settings, and interest shown by the pharmacists in matters unrelated to health, meant that patients felt genuinely ‘listened to’ and respected. Here are some comments from people the service is helping:  

"I have trouble addressing folk … I think my self worth’s been knocked that much that I don’t think I’m worthy now, you know … [Name of pharmacist] is just approachable … and you get the impression when you’re speaking to them, they’re interested in you … They’re so nice and non-judgemental, and give off the impression that they genuinely want to help, which, in the medical profession is quite rare, because they’re so busy".  

 

"They’ve got a different approach. I’m not demeaning any of the health services’ people, doctors or nurses, but you’re more at ease with them [the pharmacist and street team worker] … My doctor’s a great guy in many ways, and the practice nurses and pharmacists, but it’s a different way of approach in here [day centre]. They make you more at ease … They spend time listening to you … It makes me feel good, aye. I feel really good, relaxed, the way they come across."   

Case study 1 

Patient A was referred to the PHOENIx team by ED staff, after 7 ED presentations in 5 days due to drugs and mental health issues. The patient had 25 ED presentations in the previous 12 months resulting in 7 admissions with a cumulative total of 22 nights inpatient stay. 

The PHOENIx Team actively sought out this patient in the community, in order to provide support and intervention. The main intervention for this patient was advocacy to access support for his drug use. The team liaised closely with addictions services in order to access immediate treatment for the patient at Glasgow’s Drug Crisis Centre. Persistent and consistent follow up and support via telephone from the team throughout this inpatient stay, allowed for the patient to build a trusting relationship with the team. The team continued to work with the patient’s care manager in order to ensure suitable supported accommodation was available on discharge and that all social support benefits were in place. 

Once in the community, assessment, monitoring and prescribing for other medical conditions has been undertaken by the team linking closely with the patient’s registered GP. Social prescribing support was provided by a referral into the PHOENIx PALS (Pharmacy And Link Support) volunteer support service, to provide additional social support and meaningful activity to aid with the recovery process. 

The patient has a weekly follow up visit from the team and telephone access out with these visits. In the 5 month intervention period, the patient remains in good health, free from illicit drug use, with zero hospital admissions or ED presentations. 

Case Study 2 

Patient B was referred to the PHOENIx Team by the Homeless Liaison Nurses after a prolonged hospital stay. In the 12 months prior to this admission the patient had 4 ED presentations with associated admissions for a cumulative duration of 10 days. Within this 12 month period the patient had demonstrated a chaotic lifestyle with 2 spells in prison and 5 different places of accommodation. 

Due to the transient lifestyle of this patient and lockdown due to Covid-19, it took the team a while to locate the patient and the patient had 12 further ED presentations (9 associated admissions) within this time frame. Once located, the team were able to provide a mobile phone in order to undertake assessment and provide support including prescribing long-term medication, linking with BBV team and secondary care clinicians and helping the patient to apply for benefits. 

Once outreach recommenced, the team met with the patient on a weekly basis and linked closely with his addictions care manager. Many of the consultations were undertaken in a social setting such as a local café for which the patient referred to as ‘the highlight of my week’. 

It was noted at one point that the patient had multiple boxes of medication in his flat and so medication was switched to supervised dispensing in order to improve adherence, whilst relaying this information to the Consultant responsible for care. 

The patient was admitted to Glasgow Drug Crisis centre and on discharge had a 6 week stay in the Stabilisation Unit. The team remained in close contact during this time and played a crucial role in helping to source suitable accomodation once discharged. The patient has been linked in with the PALS service and continues to engage with both this service and the PHOENIx Team. There have been no ED presentations for the past 8 months and the patient has remained in the same accommodation during this time.  

PHOENIx is funded mainly through is short term external grants which finish in December 2021: Scottish Government / Glasgow Alcohol and Drugs Partnership (Corra Foundation); Big Lottery Fund; Drug Deaths Task Force; Pharmacy Services. Link worker support is funded through Simon Community Scotland and The Marie Trust. For funding opportunities to continue the service please call 07971827565 or email [email protected] 

Kate Stock, Richard Lowrie and Alastair Ireland

June 2021  

PHOENIx Pharmacists: Kate Stock; Cian Lombard; Becky Blair; Richard Lowrie.

 

References: 

  1. Aldridge RW, Story A, Hwang SW, Nordentoft M, Luchenski S, Hartwell G,Tweed EJ, Lewer D, VittalKatikireddi S, Hayward A. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet. 2018;391:241–50. 

 

  1. Morrison D.Homelessness as an independent risk factor for mortality:results from a retrospective cohort study. Int JEpidemiol. 2009;38:877–83.  
  1. Office for National Statistics (ONS).Deaths of homeless people in Englandand Wales: 2013 to 2017. London: Statistical Bulletin. ONS; 2018.  
  1. Waugh A, Clarke A, Knowles J, Rowley D. Health and homelessness inScotland. Edinburgh: Scottish Government; 2018. 
  1. Johnsen, S., Cuthill, F. & Blenkinsopp, J. Outreach-based clinical pharmacist prescribing input into the healthcare of people experiencing homelessness: a qualitative investigation. BMC Health Serv Res 21, 7 (2021). https://doi.org/10.1186/s12913-020-06013- 
  1. Lowrie R, Stock K, Lucey S, Knapp M, Williamson A, Montgomery M et al, Pharmacist led homeless outreach engagement and non-medical independent prescribing (Rx) (PHOENIx) intervention for people experiencing homelessness: a non- randomised feasibility study, International Journal for Equity in Health, 10.1186/s12939-020-01337-7, 201, (2021).
  2. Jagpal P, Saunders K, Plahe G, Russell S, Barnes N, Lowrie R, Paudyal V.

Research priorities in healthcare of persons experiencing homelessness: outcomes of a  national multi-disciplinary stakeholder discussion in the United Kingdom. International Journal of Equity Health 2020.19:86:1-7 

  1. Lowrie F, Gibson L, Towle I, Lowrie R. A descriptive study of a novel pharmacist led health outreach service for those experiencing homelessness. Int J Pharm Pract. 2019;27:355–61. 
  1. Hanlon P, Yeoman L, Esiovwa R, Gibson L, Williamson AE, Mair FS, Lowrie R . Interventions by healthcare professionals to improve management of physical long-term conditions in adults who are homeless: a systematic review protocol. BMJ Open 2017 Aug 21;7(8):e016756
  2. Queen AB, Lowrie R, Richardson J, Williamson AE. Multimorbidity, disadvantage, and patient engagement within a specialist homeless health service in the UK: an in-depth study of general practice data. BJGP Open. 2017;1(3):bjgpopen17X100941 https://doi.org/10.3399/bjgpopen17X100941
  1. Lowrie R, Williamson A, Spencer R, Hair A, Gallacher I, Hewett N. Collaborative engagement for long term conditions by clinical pharmacists for people who are homeless in Glasgow, Scotland. In: Paper presented at the annual policy conference of the European Federation of National Organisations Working with the homeless (FEANTSA), Gdansk, 19 May; 2017b. http://www.feantsa.org/download/march-2017-healthandhomelessness-newsletter2959399951318964653.pdf
  1. Zeitler M, Williamson AE, Budd J, et al. Comparing the Impact of Primary Care Practice Design in Two Inner City UK Homelessness Services. Journal of Primary Care & Community Health. 2020 Jan-Dec; DOI: 10.1177/2150132720910568. 
  1. Lowrie R, Hair A, Gibson L. How pharmacists are helping the homeless in Glasgow. Pharmaceutical Journal. 2017a;9(6) online DOI: https://doi.org/10.1211/CP.2017. 20202677. 
  1. Robinson J. Hope for the homeless –how pharmacy is supporting those living on the streets. The Pharmaceutical Journal, PJ August 2020, vol 305(7940):DOI:10.1211/PJ.2020.20208115
  2. Gibson L. https://www.pharmaceutical-journal.com/careers-and-jobs/ careersand-jobs/career-profile/a-day-on-the-streets-treating-patientsexperiencinghomelessness/20206339.fullarticle?firstPass=false 
  1. https://www. bbc.co.uk/news/av/uk-scotland-46573082/getting-medicine-to-homelesspeople-onthe-streets-of-edinburgh.

 

 

 

 

 

 

 

Last Updated: 01 September 2021