Is COVID-19 our chance to build a safer and more compassionate health and social care system for people experiencing homelessness?

First published December 2020 by GM PSTRC written by Martin Burrows, Director of Research and Campaigns & Mat Amp, Project Officer, Groundswell and Kelly Howells & Caroline Sanders, GM PSTRC.

Groundswell, is a charity that works with people with experience of homelessness, offering opportunities to contribute to society and create solutions to homelessness.

Two years ago we began working in partnership with the GM PSTRC on a research project that aims to understand how best to improve the quality and safety of healthcare for patients who are experiencing homelessness. We believe this is a crucial project to tackle inequalities in health outcomes as we know the level of need for healthcare in this group of people is high, while access to and experiences of healthcare are poor.

We hope that we will soon see the back of COVID-19 but we need to ensure we learn from the shifts in the healthcare system for people experiencing homelessness. It is essential that we take note of both the positive and negative impacts of changes to the health and social care system on people who are homeless during the pandemic.

Year one of the research – compassionate care and patient safety
In year one of the study, we explored the perspectives and experiences of both people affected by homelessness and staff working in the relevant health and social care settings by focusing on access to and use of healthcare. Through a series of interviews and workshops we explored how people experiencing homelessness accessed care, their perceptions of ‘good’ quality care, and how access to and experiences of healthcare might be improved.

Participants shared their experiences of when the healthcare system has not been working for them – and in some cases actively working against their interests. Challenges were common, but there were also examples of healthcare staff making a real difference to the lives of their patients.

Often what made the difference was good communication, offering a flexible approach, building trust and above all treating people with compassion. The link between compassionate care and patient safety has often been drawn, where compassion reflects a positive culture for ensuring psychological safety and positive patient experience.

Adapting the research due to the COVID-19 pandemic
Year two of the study has seen the world adapting to the COVID-19 pandemic. As a result, there has been rapid change in the provision of primary care, including organisational and technology changes to deliver remote consultations where possible. These changes raise additional challenges for delivering care with compassion when the nature of interaction with healthcare staff has changed so much.

The physical barriers are greater because you cannot enter a GP surgery freely, you cannot talk to reception staff face-to-face, and the small gestures and non-verbal cues that often reflect compassion are not easy to convey remotely.

However, the response to the pandemic in homeless services has also forced new ways of working and innovation across the boundaries between health and social care. An example of this is the way in which hostel and GP services have been working together to enable remote consultations and to prevent spread of the virus.

We do not yet have good evidence on the impact of these changes so the focus of our project has shifted to enable us to investigate this, and to support continuous learning for service improvement during the pandemic. We believe it is incredibly important to capture this to help evaluate which adaptions are making a positive impact.

Working in partnership with primary care
We have formed a partnership with three providers of primary care in Greater Manchester who are commissioned to provide homeless healthcare services. These are:

• Urban Village Medical Centre
  Salford Primary Care Together
  Bolton Homeless and Vulnerable Adults Service

Together we are capturing how adaptations to service provision are impacting on patient experience. While in the first year of the project we relied on face-to-face data collection, COIVD-19 has also forced us to shift to delivering interviews with patients and health and social care professionals remotely and staff at the case study sites recording ‘audio diaries’.

Working alongside primary care we’re able to evaluate current changes. We have seen real innovation in the way in which services have adapted in these case study sites. They have strengthened links with hostel and emergency hotel provision to be able to provide more integrated care, and received support from the Greater Manchester Health and Social Care Partnership.

Electronic devices have been provided to accommodation projects where staff have supported remote video consultations. The digital divide is a common topic of concern when discussing inclusion health, but here we have an example of a situation where, given the right support, we could improve access to healthcare.

However, there are many complex issues to consider, and we are learning from staff about the cases and contexts in which access to services may have become more difficult, as well as potential solutions to the problem of people falling through gaps in provision.

Improving medication safety – a small change making a big difference
Medication safety has long been a key concern in the context of homeless healthcare, particularly in relation to the management of addiction. During the pandemic there has been a trend in moving from daily to weekly pickups of scripts for people facing drug dependency. For people collecting scripts on a daily basis this can represent the place where the health system interacts with people’s lives most vividly.

We have heard from participants about suffering the ‘daily humiliation’ of standing in in a queue in the public gaze while dealers lurk in the midst to tempt them. We have spoken to participants for whom moving to weekly pickups has made a huge difference to their lives, allowing them, for the first time in many years, to avoid using illicit drugs on top of their scripts.

Not being on daily picks-ups has allowed them to feel like recovery is a real possibility. While the driver for this change may be a different approach to managing risk, it also represents increased trust in patients facing addiction to manage their own care.

The ‘COVID-19 positives’
With the positive news about a vaccine, we are united in the hope that we can see the end of COVID-19. It has been a trying time particularly for health and social care workers and has presented real challenges for people who are currently homeless.

That said, we also need to capture the ‘COVID-19 positives’ and the learning from how the system has adapted during these difficult times. Where adaptations in specialist local services have had a positive impact on people experiencing homelessness, we need to ensure that these shifts become embedded for future provision whilst also informing wider system change.

In this way, our study reflects the priorities of the NHS patient safety strategy in providing insight rooted in ongoing involvement of patients and service providers, and achieving impact through service improvement for some of our most marginalised communities. It is clear that, now well into our second year of the study, we are making positive steps forward. We aim to capture the changes made in primary care, understand their impacts and embed in policy and practice the positive impacts of COVID-19.