Regular GPs are the main primary health care provider for many people who are homeless, particularly outside large cities. It is therefore essential that they have the resources to support patients who are homeless, many of whom have multiple and complex health needs and find it hard to engage with services. The benefits of introducing a ‘homelessness lead’ into these GP practices to coordinate care for patients who are homeless should also be considered.
Dr Maureen Crane, Principal Investigator and Visiting Senior Research Fellow at the NIHR Health and Social Care Workforce Research Unit at King’s College London
06 October 2023
Regular GP services face challenges to provide adequate care for people who are homeless, study finds
Researchers examined four models of primary health care provision
The first UK study comparing different models of primary health care provision for people who are homeless finds regular GP services face challenges to provide the level of care seen at specialist health services, while also highlighting poor access to mental health and dental care across all models of provision.
The HEARTH study, which was funded by the National Institute for Health and Care Research (NIHR), was led by Dr Maureen Crane of the NIHR Health and Social Care Workforce Research Unit at King's as part of the Unit's Homelessness Research Programme. Today sees the publication of the study's final report (258pp) and two briefing papers, one for NHS primary care and integrated care commissioners (11pp) and one for NHS primary care managers and practice staff (14pp), which spell out the findings and implications for these professionals.
Focusing on the experiences of 363 single people who were homeless in England, Dr Crane – working with King's colleagues and researchers from the University of Surrey – found those using regular GP practices saw their GP on average just 5.8 times during the 12-month study period, compared with 18.6 times for those who attended specialist health centres designed primarily for people who were homeless. This was despite there being no statistically significant differences in the presence of physical or mental health problems between the study groups.
Regular GP practices were also significantly less likely to provide continuity of care for substance misuse issues, with just 15% of their participants with drug problems receiving this help, in contrast to 85% of such participants in specialist health centres and 56% in specialist GP practices.
More generally, regular GP participants were less satisfied with the service they received: 56% said they definitely had confidence and trust in their doctor or nurse when last seen – far lower than the proportion who said the same among those who attended specialist GPs (81%) or specialist health centres (82%).
Staff at regular GP practices reported insufficient resources prevented them from working in more proactive ways with patients who were homeless, with those attending these practices also reporting longer waiting times.
However, regular GP practices scored relatively high for health screening – almost as high as specialist health centres – and two sites had each developed a health screening template specifically for patients who were homeless, which was found to be effective.
The relatively poor performance of regular GP practices for some outcomes “raises questions” about their role in providing health care to patients who are homeless, and when these practices might require additional support, the researchers say.
Four models of primary health care provision were compared
Published in the NIHR journal Health and Social Care Delivery Research, the study compared the effectiveness of four models of primary care services across 10 sites. These included: (1) specialist health centres for people who are homeless; (2) mobile homeless health teams; (3) specialist GP services (regular GP practices with some services specifically for patients who are homeless); and (4) regular GP practices with no specialist services for this patient group.
Among the four models, researchers found specialist health centres and specialist GP sites to be the most effective overall. They provided flexible drop-in clinics and longer-than-usual GP appointments, and worked closely with mental health, alcohol and drug services, and with hostels, day centres and street outreach teams. These are all factors likely to have contributed to their success.
The study also found that although mental health problems were very common among participants, with 91% reporting such problems, staff across all four models of care reported insufficient mental health services in their area, which affected the help they could provide to patients.
While 82% of study participants described needing dental treatment, these needs were often unaddressed, even though dental services specifically for people who were homeless or vulnerable were available at or near seven of the sites included in the study.
The researchers say this can be explained by above-average levels of dental anxiety among study participants, and poor integration between primary health care services and dental services.
The research is the first to provide evidence about the effectiveness of each model of health care for single people who are homeless – a patient group with greater health needs and a far lower life expectancy than the general population.
Homeless people are among the most under-served and most vulnerable in our communities and often have very complex health needs. This is an important study and the first to compare, comprehensively, the impact of different models of primary care provision for homeless people. This study has the potential to inform improvements in the organisation and delivery of primary care services in order to meet the complex needs of homeless people, going forwards.
Professor Kathy Rowan, Director of the NIHR Health and Social Care Delivery Research (HSDR) Programme, which funded the study
This publication
Final report
Crane M, Joly L, Daly BJM, Gage H, Manthorpe J, Cetrano G, et al. Integration, effectiveness and costs of different models of primary health care provision for people who are homeless: an evaluation study. Health Soc Care Deliv Res 2023;11(16).
Briefing papers
The report is accompanied by two briefing documents – for commissioners, and for managers and practice staff – which spell out the findings and implications of this research for these professionals.
NHS primary care and integrated care commissioners
Crane, M., Joly, L., Daly, B., Gage, H., Manthorpe, J., Cetrano, G., Ford, C. and Williams, P. (2023) Integration, effectiveness and costs of different models of primary health care provision for people who are homeless: an evaluation study. Findings and implications for NHS primary care and integrated care commissioners. London: NIHR Policy Research Unit in Health and Social Care Workforce, Policy Institute, King's College London.
NHS primary care managers and practice staff
Crane, M., Joly, L., Daly, B., Gage, H., Manthorpe, J., Cetrano, G., Ford, C. and Williams, P. (2023) Integration, effectiveness and costs of different models of primary health care provision for people who are homeless: an evaluation study. Findings and implications for NHS primary care managers and practice staff. London: NIHR Policy Research Unit in Health and Social Care Workforce, Policy Institute, King's College London.
King's project page for this study
HEARTH study. Delivering primary health care to people who are homeless
In this story
Visiting Reader in Applied Social Research
Visiting Research Fellow
Professor Emerita of Social Work