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A day in the life of ... a health visitor for vulnerable adults

I have been a health visitor in Warrington for the past eight years and two years ago I took on the added responsibility of providing a signposting service for the homeless and asylum seekers. This had traditionally been provided by the health visiting service, but on the retirement of the post holder a gap was created. In order to address the needs of this service, I expressed an interest in developing the post and was allocated one day a week for this with the remaining four days devoted to my generic health visiting caseload. As an experienced public health nurse, I work to the principles of public health nursing/health visiting, which are:

  • Searching for health needs.
  • Stimulating an awareness of health needs.
  • Promoting health-enhancing activities.
  • Influencing policies that affect health.

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These principles underpin my practice and aided my development of this novel and exciting role. In Warrington, increasing numbers of individuals and families are homeless or living in inadequate accommodation, or are seeking asylum. These clients, who frequently have complex health and social care needs, are often unable to prioritise their health or access mainstream services, leaving them vulnerable to poor health and with a mistrust of mainstream services developed from their past contacts with statutory authorities. Any service for this client group therefore needed to be accessible and approachable in order to help clients regain confidence in the healthcare services offered.

In the initial stages I began to network with all local statutory and voluntary agencies in order to create strong working partnerships and also to ascertain what was required and how I was going to deliver the service, bearing in mind that I only had one day per week. The word homeless conjures up images of sleeping on the streets and begging - this is something we are all exposed to in our towns and cities and is the popular image of homelessness promoted by the media. However, being homeless can also mean being housed in hostels, bed and breakfast accommodation, and sleeping on friends' and relations' sofas. Individuals are homeless for various reasons - relationship breakdowns, job losses, mental illness, and not just for the popular perception that they have brought the situation upon themselves - much like the common and highly offensive misconception held about asylum seekers abusing the state.

In practice, I uncovered a very negative perception of the homeless and asylum-seeking communities. Staff felt at risk from verbal and physical aggression from both the homeless and asylum seekers, despite having no reason to suspect this. No preventative services existed, and patients from these communities were either persistent "temporary residents" or were not registered with a GP at all. This places an unhelpful reliance on the A&E service for minor illness, or the elevation of minor conditions into major health crises due to a lack of appropriate care. No referral systems existed for A&E staff to address the issue and refer patients back to primary care for ongoing, proactive management and support.
 
I have discovered that this patient group often presents very late in the disease process, and when they do receive the appropriate care, they often fail to complete the treatment programmes due to the lack of ongoing support with almost zero anticipatory care available to them. I also found that there were no systems in place to transfer information about the transient populations.

In order to provide a framework to develop an effective service to both the homeless and asylum-seeking communities, a number of aims were constructed. These aims are:

  • To reduce ill health caused by homelessness and promote good health in the context of unstable accommodation, increased vulnerability and experience of asylum.
  • To provide access to mainstream services for the hard-to-reach and socially excluded groups.
  • To reduce dependence on unplanned and emergency care and support and promote anticipatory care.
  • To provide an accessible, drop-in service, which can be accessed freely.
  • To promote the needs of these patient groups across the local health economy.

A drop-in session is now available once a week, held at the locally designated resource centre, for all agencies who deal with vulnerable clients. Should I need to refer the patients to a GP, I have negotiated an arrangement with Warrington PCT out-of-hours service that allows any individual who does not have a GP but requires medical attention to be seen the same day. I proactively visit the local hostels on a regular basis to provide advice and support for the frontline staff and also provide a drop-in health clinic for the hostel residents. Issues raised in this forum can range from smoking cessation and dietary advice to major health issues. When invited, I also take part in the residents' meetings and provide health education sessions. Currently I am targeting sexual health, with sessions on self- examination being offered to all residents in all the hostels over a period of several weeks to ensure maximum coverage.

When I am notified that asylum seekers have moved into the area, I invite them to attend an appointment for a health assessment using the Warrington PCT tool for health needs assessment of vulnerable adults. This has been developed in partnership with my colleague Scott Harrison, Community Matron for Learning Disabilities, to provide a flexible and inclusive model of healthcare for all vulnerable adults. The health assessments are also offered in accommodation settings, homeless centres and as part of the drop-ins at the local resource centre, as a way of "demedicalising" public healthcare and encouraging engagement with the service.

I am also a member of the local forums for the homeless and asylum-seeking communities to ensure that health has a voice in the decision-making process. What I aim to achieve over the coming months is a movement towards greater partnership working between voluntary, statutory and health agencies to ensure that clients do not "fall through the net" and are referred appropriately for routine health screening and support. I am also commencing education and training for staff to dispel the misconceptions held and provide a point of contact for advice and support. Through my work I hope to continue acting as a champion for my patients in the PCT and wider community to ensure that their needs are expressed and met both practically and strategically.