The Surrey Hills area is an Area of Outstanding Natural Beauty, renowned for its affluence. Yet when one patient at a GP practice fell on hard times and became homeless, it opened a window for staff at Shere Surgery and Dispensary into part of their community which so often goes unnoticed and undeserved. From seeking to do right by this one patient, Shere Surgery has become a champion of health equity for those experiencing homelessness. As a result, they were recognised as a RSPH Health and Wellbeing Award Finalist in 2021.  

What was the problem? 

In the UK, to register with a GP and access the full range of primary care services, one has to provide proof of address. This allows someone to establish their right to free treatment on the NHS. But it can have incredibly harmful effects on those who become homeless. Their living situation puts them at far greater risk of illness and injury, and at the same time, prevents them from accessing the care they need more than ever. 

This was brought home to us at Shere Surgery when one of our patients was evicted from the property he was renting and became homeless. With significant cardiac problems, he needed regular medication. If he was no longer able to access our services, then he would not be able to be get repeat prescriptions and his health would be at serious risk. As we had already built up a good relationship with this patient, who had an ongoing history of drug use, we wanted to continue to offer him support.   

Through this patient’s change of circumstances, we became more aware of the hidden homeless around us, 24-hour carers moving house-to-house, people living in cars or barns. At the same time, we began to look into what local support services were available for those rough-sleeping in Shere. While urban centres have specialist services to cater to those experiencing homelessness we discovered that the homeless in our otherwise prosperous and rural location are assumed to not exist. They might stay here to be safer or because it is familiar to them, but that means there is less awareness about, and fewer systems in place to cater to their needs. 

What we did 

To address this gap, we approached the Clinical Commissioning Group (CCG) for permission to hold a Locally Commissioned Service (LCS) for Homelessness, to allow us to register patients for full GP services without needing to provide proof of address. Of 21 GP practices in the CCG, only one other was signed up to offer this service. 

The practice is now able to register homeless patients and keeps an up-to-date register of these patients, ensuring that those who were previously unable to access any General Practice care, now have the same access to all of our services as any other patient. We are also able to support equity of access to secondary care: by using our surgery address for them, we are able to refer them to hospital services, and can help manage communications regarding their appointments. 

As well as being able to access mainstream GP services, we also offer to our homeless patients: 

  • A welcome chat with our Lead Administrator, who helps with the registration paperwork, introduces patients to our services and how to access them.  

  • Annual health needs assessment including access to screening where appropriate  

  • Catch-up immunisations  

  • Ongoing vaccination for flu and Covid-19  

  • Help from our Lead Administrator with filling in forms and signposting to parallel support services (Social Services, Homeless Outreach Support Team) who can help with housing, finances and benefits, showering/sanitation, employment. 

  • A drop-in service with the lead GP where possible (this really isn’t overused) 

  • Ensuring free prescriptions through our on-site Dispensary, where staff make sure to ask for the name and date of birth (instead of name and address) when the system flags that the patient they are serving is on our homeless register. We have heard from patients that this small modification, made to avoid embarrassment or stigma, is hugely appreciated. 

Most of all, we offer an open, non-judgemental service, which, our patients tell us, helps them to feel welcome, human, and normal. The outcomes of our service are hard to measure. There are likely to be cost savings to the healthcare system as a whole in the long-term, as early intervention prevents health conditions becoming more serious and therefore, harder and more expensive to treat. Similarly, without access to primary care, people experiencing homelessness can only seek treatment through A&E – where the pressures on the NHS are already greatest. 

With around 15 patients on our homeless register at any one time, the scale may be small, but to those individuals, it is invaluable. The life expectancy of men experiencing homelessness is 45. For women, it is 43. This is decades less than the national average of 79.4 for men and 83.1 for women. Just as shocking is the fact that one third of homeless people die from treatable illnesses like tuberculosis, pneumonia, or gastric ulcers. Another third are caused from drug poisoning – deaths which could have been prevented from access to addiction support services.  

So, from our perspective, success looks like seeing homeless patients receiving the same care as everyone else, able to for once feel equal, and thereby defy these horrifying statistics. 

How you can do the same 

As well as being incredibly valuable, our project required almost no extra resources – just enthusiasm for the work and compassion for the patients. So I would highly recommend other GP practices do the same, as the process is simple and straightforward: 

  • Apply to your CCG for a Locally Commissioned Service for Homelessness 
  • Generate enthusiasm in your team for the project – we recruited a Lead Receptionist, Nurse & GP to lead the project but your service may work differently.  
  • Consider using a coding template in your clinical recording system. This will create prompts to ensure that the team covers all relevant aspects of care for each patient and that all information is auditable in order to understand populations and further plan services. 
  • Actively recruit into the service – inform local homelessness charities and stakeholders so they can directly refer patients to the practice. We also left invites where we knew people were sleeping rough. 
  • Remember the first contact is the most vital: our reception team are welcoming and open, non-judgmental and proactive. 
  • Gather regular feedback from all stakeholders to ensure the service meets its purpose as it evolves.