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Improving outcomes for vulnerable patients

A specialist service has been developed to meet the needs of hard-to-reach patients, with impressive results, writes Dr Pip Fisher

Dr Fisher: health is not a priority for many of our patients, who include homeless people. Image Alex Deverill
Dr Fisher: health is not a priority for many of our patients, who include homeless people. Image Alex Deverill

The Whitehouse Centre was established in 2001 as a specialist practice to provide primary care for hard-to-reach groups: asylum seekers, refugees, substance users and homeless people in Huddersfield.

Our four part-time GP practice is town centre-based with only a small list of 1,100 patients, but it can take patients from anywhere in the Huddersfield area.

We have very few ‘mainstream’ on-going patients: ours is a relatively young population, who suffer a high prevalence of severe mental health problems and have difficulty accessing mainstream services.

To meet the needs of our population, we have adapted how we work. Our new patient assessment includes not only past medical history and routine health promotion but catch-up vaccination; testing for blood-borne viruses and haemoglobinopathie; an explanation of how to access care; and, in the case of asylum seekers, enquiry into a history of torture or imprisonment. This helps us provide holistic care despite a high patient turnover that is, at times, up to 75% per year.

Flexible appointments

Our appointment system has considerable flexibility. We offer 15 minute-slots (longer if required), routinely use telephone interpreters, and can accommodate the high proportion of patients that book same day appointments.

We also offer drop-in lunchtime services three days a week for those patients who repeatedly fail to keep appointments. For patients that do have a history of failed appointments we give a small card detailing when our drop-in sessions are.

We have a ‘green list’ of the most vulnerable patients (for example, those with those with psychotic illness, or at risk of domestic violence) who are seen whenever they attend the surgery.

Health is not a priority for many of our patients so it is up to us take a proactive approach. The records of those on the green list are reviewed monthly to ensure that appropriate follow up has been provided.

In addition, all repeat prescription requests are scrutinised by a clinician as they provide another opportunity to review the patient’s record and improve attendance.

We maintain close relationships with other services locally, including a fortnightly housing advice clinic offered at the surgery and to which we can refer patients that need help in accessing appropriate benefits or managing debt, for example. That way we can address some of the root causes of our patient’s health problems.

We work closely with a local drop-in centre for the homeless (where we are about to start an outreach clinic) as well as the local women’s refuge and local charities such as Simon on the Streets and Destitute Asylum Seekers Huddersfield.

The success of our approach is evidenced in a number of ways. Among the at-risk groups for blood-borne viruses our testing rates are as follows: 74% of our African population have been tested for HIV (11% are HIV positive); 76% of our Pakistani population have been tested for Hepatitis C (one Pakistani patient was found to have a past infection) and 92% of our Chinese population for hepatitis B (8% infective).

Meanwhile, 18 drop-in patients have accessed us an average of five times over the past six months and 20 green list patients an average of 11 times each over the past six months.

In terms of actual outcomes for individuals we have also had some success stories: one former substance misuser who had years of failed appointments and self-discharges from hospitals has finally been treated for pulmonary hypertension (due to recurrent pulmonary emboli) in a tertiary centre in Cambridge; a homeless alcoholic has completed surgery and chemotherapy for rectal cancer; and an Eritrean patient with no English completed breast cancer treatment.

Additionally, medico-legal reports obtained for victims of torture, after we alerted their solicitors to medical evidence (such as scarring), have affected the outcome of their cases positively.

Crucially, we regularly teach on the work that we do caring for the hard-to-reach. We speak at various conferences and teach groups of GP trainees and nurses as well as Leeds and Manchester medical students. It is an important aspect of what we do.

Key tips on tailoring services

  • Make sure you have buy-in from all your team - the nurses and reception staff are key.
  • If you operate a ‘10 minutes late and we won't see you’ system, you won't see your most vulnerable patients.
  • Check contact details at every opportunity. Vulnerable patients move around and change mobile phones frequently.
  • Ask secondary care to provide a copy of the times and dates of appointments for your most vulnerable patients, so that you can remind them. This will help increase attendance rates.
  • Forge links with the social care services, voluntary groups and charities locally. Housing, a food parcel or an English class can make more difference than any tablets you might prescribe.


Dr Pip Fisher is a GP at the Whitehouse Centre in Huddersfield.

  • This initiative was shortlisted for the 2013 GP Enterprise Awards.

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