Robbie: A homeless patient’s struggles with the system

Summary

This blog is part of a series written by Dr Charlie*, taking a closer look at some of the patient safety issues affecting people lives today. In this blog Dr Charlie describes how their homeless friend Robbie* has struggled to access the care and clarification he needed around his liver abscesses.

Dr Charlie explains how important it is for healthcare professionals to take into account individual circumstances if they are to provide people with the information and care they need.

*not their real name

Content

I have a homeless friend. He has been living on the street for many years and did so throughout the pandemic. He does not have a mobile phone and we connect either in person, by calls from a phone box or through email.

Many people assume that those who are homeless are either addicted to drugs or alcohol, or have mental health problems. My friend, who I will call Robbie, has none of these issues. He is someone who is incredibly helpful to other vulnerable and disenfranchised people who do not have homes (and some who do). He gets his healthcare from a GP who does a clinic at one of the drop-in centres he goes to. He has no address for a letter to be sent to, but Robbie does use email during library opening hours.

Initial concerns for Robbie’s health

When I did not hear from Robbie for a while, I was concerned. Robbie had spent a long period of time in hospital over the Christmas period having been diagnosed with liver abscesses. When he was well enough to leave hospital, he was prescribed a long course of antibiotics and given instructions that he would need to be kept under review. He was told that he would need to return for an evaluation in two weeks.

When Robbie went to his appointment, nobody seemed to know where he should be. Eventually he found himself in a part of the hospital which, judging from his description, may have been an ambulatory emergency care service. While someone was trying to get hold of his records, Robbie asked the doctor if he could have some more investigations to establish whether he had any resolution of his liver problems. The doctor agreed and he had blood tests and another scan.

The abscesses had shrunk to some extent, and the doctor gave him the dimensions, which Robbie wrote down. Although considerably smaller than before, one of the abscesses was still large which was alarming.

Further tests, antibiotics and a colonoscopy

Robbie was told that he needed further tests to establish the cause of the abscesses – so far, all other tests had not given the answer. He was also told that he needed to continue the antibiotics, which had to be taken with food. At the same time, he was told he needed a colonoscopy and instructed that he would need to take ‘bowel preparation’ medication to make this possible. He was given some sachets to take before the investigation.

Left confused and uninformed

Robbie lives on the streets. He called from a phone box and explained his situation to me. He was concerned because the doctor hadn’t been very forthcoming with information and Robbie didn’t know whether he should stop the antibiotics in order to have the bowel preparation medication.

I asked Robbie if he was aware that this medication would give him severe diarrhoea and that he was going to have to have access to a toilet. Robbie did not know this. I was very concerned wondering how he would cope. Robbie was more concerned about whether he should continue the antibiotics or not. He said he couldn’t swallow it without food.

Trying to get clarification

I suggested that we try and find out which consultant he was under, so he could get satisfactory answers to his problem and try and find a way of getting him at least admitted the day before the colonoscopy so that he could take the medication. I did an internet search for that hospital, looking at the names of gastroenterologists. Robbie recognised a couple but wasn’t sure which one was leading on his care. I suggested he give them a ring.

The next time Robbie called me, he explained how difficult it was to get through to the medical secretaries from a phone box. Eventually he reached someone and having explained his problem, he was instructed to turn up at a different hospital on a certain day to speak to the consultant.

Robbie got himself to the hospital, but it just happened to be the day of the consultant strike. The consultant was not available and try as he might, Robbie was unable to get any further information. Instead, he was told that the appointment would be rescheduled.

Still no answers

The problem is that Robbie still doesn’t know what is happening. He is still very worried about the size of the abscess and what has caused it. He doesn’t like the fact that the next appointment was now rescheduled for three months’ time. He says he missed an email which came too late for him to respond and is concerned that this has meant he has been ‘black-listed’ by missing an appointment.

I've explained that on the contrary, his circumstances should certainly have been taken into account, and provision made for him to get help and information should he need it.

Delays and bias potentially harmful

I have my own fears for Robbie. I have told him that it is possible that he has a serious condition in his bowel like cancer and he does need to get the investigations completed. Robbie was not aware that this was a possibility. When I met with him, he looked thin and not as well as in the past.

I am concerned that Robbie is not receiving the care that he so badly needs and that he is being overlooked because he is homeless. I wonder how much the people who work in the appointment’s office know about Robbie. Would they know that despite his homeless ‘status’, he is someone who has an engineering degree, is exceptionally intelligent, gifted and an amazing member of the community? Or have they written him off because of his position in society or made assumptions about him?

I am aware of the way doctors, nurses and others who work in the NHS have compassion fatigue and are often too busy to rid themselves of the intrinsic bias which can mean that those who are homeless are treated badly.

Final thoughts

Every healthcare encounter needs to be an opportunity to address issues which for other people, may be solved by a quick phone call or a letter through the post. Even access to bathrooms, food, drink, a bed, all luxuries we take for granted, cannot be overlooked when providing care and communicating to patients.   

This is a patient safety issue. When a patient is vulnerable, disenfranchised, marginalised and without family, then surely the NHS has more responsibility than ever. Yet I fear for Robbie. He is my friend and I do not know how I can do more from a distance. I cannot help worrying that he won’t get the care he is entitled to and deserves. He is a competent individual and our communication is limited because of his circumstances.

My real worry is whether there will be someone suitable to advocate for him in his time of need.

Related reading: Digital-only prescription requests: An elderly woman sent round the houses

About the Author

Dr Charlie is an Emergency Physician with many years of experience working in A&Es in the UK. Dr Charlie also has a family with children and identifies as someone with extensive lived experience as a patient. Knowing what is possible and what is achievable even within imperfect systems, Dr Charlie has a passion to improve patient care.