In our ‘Not your average practice’ series we speak to the GP practices with distinct patient demographics to find out how they run. The Doctor Hickey Surgery has been dedicated to treating the homeless population in Westminster for nearly 40 years. Maya Dhillon sat down with GP partner Dr Paul O’Reilly to talk about his experience of providing care to a homeless population.
‘How many people would you have to piss off before you had to sleep rough tonight?’
It’s a thought experiment that Dr Paul O’Reilly often poses to his students. They are usually shocked when that number comes out at about four or five. He continues: ‘After parents, siblings and really good friends are gone – who else is left when the brown stuff hits the fan?’
Dr O’Reilly has been a GP partner at The Doctor Hickey Surgery in Westminster for 25 years. He and his team are experts in providing care to homeless people. They serve approximately 2,400 patients, 82% of which are male. The surgery treats the full spectrum of ‘statutory homelessness’. This includes: rough sleepers; hostel dwellers; sofa sleepers; asylum seekers in hotels.
He goes on: ‘Talking about relationships may seem an odd place to start in regards to homelessness. But the diseases that cause homelessness are those that fracture your ability to form and maintain relationships. I’m talking about drugs and alcohol dependence, chronic and severe mental illness, schizophrenia, bipolar, mood disorder, the extreme end of neurotic illness, PTSD, obsessive compulsive disorder etc.’
The Doctor Hickey Surgery started in 1987 as the personal mission of a nun called Dr Mary Hickey. Upon returning from Zambia to her London convent, she was not given a job by her French Teaching Order, and spent her spare time wandering around Westminster. She noticed a lot of homeless people who did not look like they were getting much of a service and knew she had to do something about it.
With a borrowed office, prescription pad and furniture she began to see patients. It wasn’t long before she had a proper premises, after speaking to the Archbishop of Westminster. ‘I’d like to think that we have professionalised a little from that point,’ comments Dr O’Reilly, ‘but that was the foundation of it.’
Nowadays, the practice is made up of: four GP partners, two advanced nurse practitioners; a couple of nurses and HCAs; and front of house admin staff. Dr O’Reilly says that the latter are the most important: ‘It’s like retail – you just have to win the first thirty seconds. If you can meet people with a smile, a cup of tea, a sandwich and make them comfortable, then they are going to be okay.’
Dr O’Reilly doesn’t shy away from the fact that his distinct patient population presents different challenges in how the practice operates. ‘In order to use our system, you have to book an appointment, but that doesn’t mean quite as much to us as it would in most practices. Mary [Hickey] used to say “If our people could keep appointments, they wouldn’t be our people!”
‘Drug users are the busiest people in the world. They run on five hour days because their intoxication withdrawal cycle is very short. If I say to them that I need to see them next Monday at 12:30pm for an appointment, they’ll nod their heads. But they have no idea where they are going to be then. It’s like me asking you for an appointment on Monday 14 July 2030.’
Getting people registered and into the surgery in the first place is an equally tricky feat. ‘People used to just rock up. Nowadays you occasionally get outreach workers registering them online by the time they get to us which is nice. Because, if you are a homeless person in distress or going through opiate withdrawal, the last thing you want is to be confronted by a form.’
‘When we were first set up, the CCG and PCT wanted us to make a record of all our new patients and their referral origins. So we asked each patient: “Who was the last person/human being who said you should come here?’ 90% responded that it was another homeless person.’ At that point, Dr O’Reilly realised that advertising or professional recommendation doesn’t make people aware of the surgery’s presence; it was word of mouth.
‘There’s a spirit of the blitz community feeling to being a rough sleeper’ he says. ‘They value the recommendations that come from within the community more so than those outside of it.’ In light of that, Dr O’Reilly and his team put themselves out there and make themselves as visible as possible. They do a lot of street outreach, visit hostels and day centres: ‘Essentially we just provide as many opportunities as possible for people to access us as we can.’
In terms of the cases that Dr O’Reilly and his team see, he notes that many of the people he sees have conditions that have a technical solution or remedy. If someone is using Class A drugs, there is opiate substitution treatment that can be given. If someone is struggling with severe mental illness, they can acquaint them with their previous antipsychotics. ‘In those cases, good things happen quickly. It doesn’t take a lot of medical knowledge to be able to make a lot of difference in their lives.’
Though The Doctor Hickey Surgery has been operating for the best part of 40 years, the staff still learn something from their patients everyday. Their PPG doesn’t quite work like most surgeries’ might. ‘They are rubbish at sitting around, drinking tea and talking about practice policy. They need a job to do.’ Recently the PPG renovated the neglected front garden outside the surgery. The group divided the garden into two: one side is now an outdoor waiting area; the other is a memorial garden for patients that have passed away, their names written on plaques.
‘I have to confess that it is something I never would have thought of,’ comments Dr O’Reilly. But it brings up a sombre truth. The average age of death for the general homeless population is between 44 – 48; that number drops to 34 for those on the streets who inject drugs. ‘The average age at death of our practice population is currently 54 – a number of which I never know whether to be proud or ashamed. It is a measure of how much we are prolonging and improving their lives, but also a constant reminder of how much more there is to do. Our people will have broken a lot of relationships before they died, so being able to have a space in our practice for people to be remembered is really precious.’
Talking about if there are any particular challenges in caring for his population, Dr O’Reilly brings up two points. The first is that rough sleeping has always been here: ‘Every Dickens’ novel, bar one (Tale of Two Cities), mentions rough sleeping. This is not a new problem.’ Dr O’Reilly points out that the diseases causing homelessness are way beyond the Government’s power to do anything about. He admits that this renders his team slightly sceptical of programs designed to cease rough sleeping and ‘end’ homelessness – though he doesn’t wish to discourage these attempts.
The second point is that the homeless population is constantly shifting – it is not a monolith and changes over time. ‘The cycle is roughly four to five years. Then you need to completely reinvent yourself for the new needs of the new population.’ He mentions the different eras of drugs (heroin in the 80s, crack cocaine in the 2000s, a form of synthetic cannabinoids called ‘spice’ currently). But there is also migration to consider, which comes in successive waves from various parts of the world. Much of this is dependent on geopolitical matters: The Doctor Hickey Surgery sees a lot of patients from East Africa, Ethiopia, Somalia, Afghanistan etc.
This shift in population patterns becomes relevant again when Dr O’Reilly is asked what advice he would give to GPs about caring for homeless people. He is careful to avoid making generalisations, and says: ‘Homelessness is different in every single borough in London and beyond. Please find out who the poor homeless people are in your place and see what’s being done for them. And maybe you can prescribe yourself as the answer.
‘Mary used to say that homeless medicine was the most fun you could have without getting referred to the GMC – it is just endlessly rewarding. Every day you meet people who have – to be frank – a lot wrong with them. You cannot make everything better, but if you can make one thing better for them, you’ll be their new friend for life.’
See more from our ‘Not your average practice‘ series
Well done Paul on the fantastic work you and the team are doing!