Irish Street Medicine Symposium 

28 – 29 September

2018

Call for Action

Expansion of discussion  

Participants called for immediate government action on the below areas if lives are to be saved in the coming months:

• Improving care and protection for Rough Sleepers in Extreme Weather Conditions

This thought-provoking workshop aimed to develop system wide capacity to protect the health and wellbeing of rough sleepers in extreme cold weather. Storm Emma earlier this year brought life threatening conditions for the most vulnerable in our society. While the aim was to get people in from the extreme weather, personal self-autonomy meant that some stayed out with detrimental consequences.

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Rough sleepers joined this working group including a wide range of health and social care workers. Recommendations include the establishment of a ‘task force’ responsible for devising and coordinating the response to protect the health of rough sleepers in the extreme weather. This TF would have a budget to ensure appropriate equipment is available to safeguard the health of those who decide to stay out in extreme weather. It would have representation from accommodation, outreach and health services that work with rough sleepers.

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Consensus statement: Not all rough sleepers will agree to go into emergency / hostel accommodation in extreme weather: an alternative strategy to protect those who choose to stay on the streets in extreme weather needs to be developed and appropriately funded. The specific needs of this cohort of people has to date been largely overlooked.

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The overall solution to sleeping rough is drastically improved through the prevention of homelessness from all entry routes and the expansion of long term housing solutions for those currently homeless (such as housing first programmes).

• Identification and first line management of adults at risk of malnutrition

​This workshop dealt with an often taken for granted subject of nutrition. The importance of the topic is underscored by the fact that 20% of the homeless population are likely to be malnourished (cite reference). Participants were shown practical tools for malnutrition screening and educated on the use of oral nutritional supplements (ONS), and the management for adult patients at risk of malnutrition.

Consensus statement:  the need to formally measure the extent of malnutrition in the homeless population for the first time in Ireland to get a true sense of the scale of the problem (similar exercise being completed in London).  Provision of high protein and high calorie meals and snacks as a standard should be provided for homeless people at risk (night shelter, rough sleepers) to prevent malnutrition. All stakeholders as well as the HSE should have a role in developing, educating and monitoring nutritional standards and services for homeless services and direct provision centres.

• Hospital to home: Integrated solutions to enhance safe, appropriate and efficient discharges for people experiencing homelessness in Ireland

​Participants attending this gained a deeper understanding of personal experiences, service challenges and positive developments in relation to hospital discharge for people experiencing homelessness in Ireland as they try to recuperate on the streets after for example major surgery with no bed or family support. Participants contributed to integrated approaches to ensure people in homelessness experienced safe, appropriate and efficient discharges from hospital.

Consensus statement: Safe, appropriate and efficient discharges from hospital should be guaranteed for people who are homeless with access to appropriate follow-up care and accommodation in the community where they can make a full recovery.

• How the Mobile Health and Screening Unit can improve health protection among vulnerable groups: a public health perspective

​Safetynet Primary Care introduced its new mobile health and screening unit and the recent work, which focused on tuberculosis active case among homeless in Dublin and with HSE Public Health in Galway. Participants identified a range of areas and gaps in the system that the new unit with on board Chest X-ray could help fill. 

Consensus statement: If TB is to be eliminated in marginalised populations in Ireland consistent resourcing for active case finding and appropriate follow up and treatment is required.

This workshop also overviewed the work of the unit in migrant health care.

Consensus statement: All patients attending GP practices should have free access to high quality interpreting services when required, so that doctors can talk to their patients, and patients can understand and discuss matters with their healthcare providers.

• Developing Ireland’s first step-up step-down Intermediate Care Centre for homeless people

Dublin Simon and SafetyNet introduced the new Step Up Step Down unit that provides 12 beds for homeless people in need of medical or nursing care. This working group discussed arranging admission, establishing/maintaining accommodation on discharge, managing substance misuse/dependence, both treated and untreated and how the unit could augment/facilitate existing services.

Consensus statement: Night shelters should only exist as a last resort. The focus needs to be on the provision of Supported Temporary Accommodation. This would reduce the numbers of homeless forced to wander the streets during the day, potentially further compromising their health.

• Clinically assessing complex homeless patients and maintaining engagement: key nursing skills

This group discussed the need for different or enhanced approaches to meet the health needs of excluded groups. Participants were updated with evidenced methods appropriate to the new emerging discipline of Inclusion Health.

Consensus statement: Inclusion health is emerging as a distinct specialty across all healthcare disciplines. New models of care and styles of clinical engagement need to be developed and supported.

Process working groups discussed ways of improving methods of improving and developing services these included

• utilising change management theory to make changes in the system of health care provision to ensure service are prioritised for those who need them most and,

• the development of an Irish forum on Inclusion Health which would include a wide range of disciplines aimed at sharing and improving the knowledge base to improve inclusion health practice.

• Assessing Capacity

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There are times when homeless patients fail to engage the clinician has proposed treatment plan, and times when medical or support teams are concerned re their ability to make their own decisions. This issue commonly arises in the homeless sector where people can be very sick and affected by temporary or permanent loss of capacity. This workshop looked at ways of assessing a patient’s capacity for such decision making using best practice. In the context of changing legislation to support patient’s wishes and desires, the workshop provided deepened understanding and clarity on when it is appropriate for patients make personal decisions and when it is appropriate for the clinician to intervene.

Consensus statements: An agreed capacity assessment approach to assess a person’s ability to make vital choices should be implemented across services. This would be in line with new legislation on capacity assessment and the Mental Health Act.

A range of long-term accommodation options for homeless people with chronic mental health illness that provide varying levels of support. (A half way between a secure psychiatric inpatient unit and a doorway for homeless people is required)

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