Wan-Ley: I often work to their agenda first of all, to see what their problems are, and offer them that as the main thing that we deal with to show them that I will take their problems seriously, and that’s what’s important to them. 

Rebecca: So hello and welcome back to season two of GPs Talk Cancer. I’m Dr. Rebecca Leon and joining me again through this podcast is Dr. Sarah Taylor. We are both practicing GPs and GP leads for Gateway C. We both passionate about diagnosing cancer early, and in this podcast we want to share our clinical experiences with you so you can make better, faster and more confident cancer diagnoses in primary care. 

 

So, there’s some official stuff to make you aware of. We know this podcast might be of interest to anybody, but it’s really aimed at primary care health professionals. And although all patient cases are based on real stories from clinical practice, they are fully anonymised with no identifiable patient data. 

 

Gateway C is the free early cancer diagnosis resource funded by the NHS and is based at the Christie NHS Foundation Trust. GatewayC is a national programme across the whole of England, Scotland, and Wales. Register online to gain access to free interactive courses, documentary-style videos, referral maps and more. 

 

Today we’re going to sit down for coffee and talk about cancer when you have no fixed abode. And joining us today is our guest, Dr. Wan-Ley Yeung. He’s a GP and clinical lead of the GP Inclusion Health Service at Salford Primary Care Together, among other roles. Wan, lovely to have you. 

Wan-Ley: Nice to be here. 

Rebecca: Wan and I are very old friends. We need to just… We have been friends for about 25 years. Yeah, first day of medical school! So it’s a real pleasure to have you. 

Wan-Ley: Thank you! 

Rebecca: And Sarah, good to see you. 

Sarah: Yeah, and you’re poorly again. 

Rebecca: Yeah, but I don’t really want to dwell on that. 

Sarah: No, don’t! 

Rebecca: No, but no, I’m okay. I’m getting over another bad cold, but it’ll be the last of the season, I promise you. 

Sarah: Excellent. 

Rebecca: And how’s the running? 

Sarah: Yeah, good. I’ve been this morning. 

Rebecca: Yeah. Marathon for you next year? 

Sarah: If I get a place, but I’m sort of hoping I probably don’t.  

Rebecca: It’s always if I get a place.  

Sarah: Yeah, well, I’ve got to put a ballot entry in with my daughter. So if we, if we both get… if one of us gets it, we’ll do it. 

Rebecca:: Cool. Are you a runner? 

Wan-Ley: No, not me. 

Rebecca: You a cycler? 

Wan-Ley: I did cycle here, yeah. 

Rebecca: Did you cycle in this morning?  

Wan-Ley: Yeah. Lovely day for it. 

Rebecca: It is a nice day, yep. Okay, so I’m excited about today’s topic because I think it’s something that we haven’t really touched on before and I hope it’s going to provide a lot of interesting chat. I do have a stat, and unfortunately with this cohort of patients, there aren’t many statistics but the average age of death for people experiencing homelessness. It’s 46 for men and 42 for women, which compared to housed men and women, it’s 78.6 age for men and 82.6 for women. So that is a shocking statistic. 

Wan-Ley: That’s a really sobering fact. 

Rebecca: Why isn’t there more statistics in this group of patients? 

Wan-Ley: I think it’s very difficult for… recorded… people to record kind of details on this population. They, they move around, they travel around a lot and they have no fixed abode so you can’t lock them into a space where you can kind of gather that information and people aren’t gathering it as much as they could be. I think, hospitals and GP practices could be asking people about their housing status and that would really help to create more data that’s available for us.  

Sarah: And presumably it’s a fluctuating status as well, isn’t it? So people sometimes housed and then… 

Wan-Ley: Absolutely, which is why we talk about people who are experiencing homelessness because they shouldn’t be labelled by their housing status. But it’s something that people go through. 

Rebecca: So we’re going to do things slightly different today. Case studies will be discussed, but they’ll be intermingled throughout the talk. So normally we start with cases, but actually we’re going to talk about a few things first, if that’s okay. Can I just ask, what is the difference between no fixed abode and inclusion health? 

Wan-Ley: Well, Inclusion Health kind of is a broader brush that covers people that have had social exclusion, so suffer from multiple disadvantages because of problems like poverty. It includes people that don’t have an actual home, but it’s a broader definition, including people that might be seeking sanctuary in the country, people that are sex working, traveller communities that don’t have accommodation which is kind of fit for purpose. So living in kind of caravans and things without running water, and people that live in kind of makeshift tents or makeshift shelters and people in, kind of, in contact with the justice system and victims of modern slavery and they all tend to fall in and out of having no fixed abodes, so there’s a broader umbrella title that kind of looks after all of them. 

Sarah: And I know you’ve, you’ve spoken before about you like the term, the term of no fixed abode rather than homeless. So, what… because that includes a bigger group of people, doesn’t it? 

Wan-Ley: Yeah that’s right, so well it’s the broadest kind definition of it would include people that are rough sleeping is what people think about when they think about people that are homeless, but people that are sofa surfing, people that may have gone back into their relatives homes having lived independently for a while, they’re, technically speaking, homeless. People that are under eviction, and they, they, they have to leave their home by a certain point, they’re counted as homeless. And people that don’t feel safe to go back to a space, so people that are in domestic violence relationships, they cover homelessness. But also, insecure housing, so people that live like in caravans, so travellers, Gypsy Roma populations. And then sex workers as well often fall under inclusion health as well, because they often fall into that homeless state and it’s a way of kind of categorising them, because they often suffer from the same problems that a lot of these other groups face as well. 

Sarah: And my experience from my practice in Manchester is that the number of homeless patients that we have is going up fairly significantly. Is that reflected…? 

Wan-Ley: The numbers are really going up, which is why I kind of really encourage GPs to start to record housing status because, we’re a specialist GP practice and so we see a relatively high number of them. But they’re all over the place, you know, they’re sofa surfing. They’re probably people that are your patients already that have fallen into homelessness because the times are really hard. The cost-of-living crisis is really hitting a lot of people. 

Rebecca: Wan, can you tell us a bit about your line of work? I mean, you mentioned that your particular surgery specialises in this cohort of patients, and how you became more involved in looking after people of no fixed abode. 

Wan-Ley: Sure. So it’s, so I originally came into it ’cause I was, it was part of the company that I worked for was a community interest company. And so, any profit that the company gets made gets driven back into community projects. And so at the time they were working at a night shelter, probably about seven years ago and they, there was a, a vacancy for a, a GP to work there in the drop-in centre. So I said, yeah, I would do that. And then, shortly after my clinical lead left the role and so they just asked if I’d carry on and they said it’d be really easy, nothing to do. And when I looked into it. I could have let it tick over, but I realised there were lots of gaps in the system, and so I started to make contacts with lots of other organisations, because really, through partnership and collaboration, that’s the way that we’re going to help people to recover and get out of their situation, and so I started to make lots of contacts and build a network, and then slowly that grew and grew, and that kind of got me to the position that I’m in now. 

Rebecca: And what is your position? 

Wan-Ley: So now I’m the GP clinical lead for the Salford Primary Care Together Inclusion Service and that mainly means that I, I lead on clinical decisions, I, I help direct where we’re going, whereas we’ve got some really good service managers and, and people that kind of make sure that things are done kind of properly. 

Rebecca: Aw, proud! 

Wan-Ley: Thanks. 

Rebecca: So, we’ve talked about, you know, the patients that are included in Inclusion Health or No Fixed Abode. What symptoms, or we’re talking about cancers because this is our podcast, what symptoms do you see and what should we be concerned about with these particular patients? 

Wan-Ley: So, it is difficult. I wouldn’t claim this is easy. Things that we get taught kind of in medical school about kind of red flags. Patients often have these kind of red flags. And you have to kind of really pick out the history and really make sure that, is this part of the story that they’re giving or is it part of a cancer that you’re concerned about? And one of the really big things that we need to really have is a really good relationship with the patient because, in one of the cases that we’ll speak about, if the patient came in and he, it sounds like a really kind of barn door case where he said, I’m coughing up blood and I’ve been coughing up blood for this long and most people would think, well, we need to refer them down a cancer pathway. But if I’d said that to him, he would have just not gone to the appointment and that wouldn’t have helped anyone really. So it was a case of building rapport, finding out what his thoughts were and, and respecting that and going down some of that line so that he could understand that this was a trusting relationship and that relationship is really important in inclusion health. 

Sarah: The problem with some of that though from, because we’ve got quite a lot of homeless patients now, is that sometimes we don’t see them for months on end and there’s that tendency when they’re moving around to think I’ve got to do everything… 

Wan-Ley: Yeah. 

Sarah: …At that one appointment, because they may never come back and see me. And so how do you balance all of that up in your mind?  

Wan-Ley: So fortunately in the inclusion service we do get extra time so that we can do that because you’re right, sometimes we might not see them for ages, but now that we’ve got this shared record across Greater Manchester, it’s really important that, If we can get as much information as we can do, it’s there so that it can be picked up by someone else if they come across that patient. So we start off with a new patient screening questionnaire where we ask them about things, like their past history, their past traumas, any kind of criminal activity they’ve been involved in, the drugs and alcohol dependence. And then we also do a full blood screen, including blood borne viruses. We try and capture as much information as we can do, so that if they don’t show up again, then when they do bob up again in a few months time, that information’s there and ready to be acted on rather than having to start right from the beginning again. 

Rebecca: That’s really good because you say we have like 10 to 15 minutes and we’re and it’s, we can all think about those patients that they come and then we don’t hear from them for for six months. 

Sarah: And you’re stuck with a way of contacting some of these patients, aren’t you? Because, you know, I can think of one who’s very similar to the case that you were describing here, who, you know, you try and phone him with some blood results, and you can’t phone him because you haven’t got the right number. He’s moved out of the homeless shelter that he was in when he came to see us. And thankfully, the patient I’m talking about now has a really good support worker so I can call her and say, please can you talk to him and can you come and see me and this sort of thing. But actually, it can be really difficult to find people, can’t it? 

Wan-Ley: And that’s why I was talking about collaboration and partnership. Having those support workers is really important because they’re often the first point of contact for the people experiencing homelessness. So they’ll speak to them and ask them about how they’re going to get any kind of benefits at all or how they can get rehoused and things. So they are an important part in their, figure in their lives. And so having that contact point really helps us to kind of make sure that information can be kind of travelled across.  

Sarah: So what cancers are we concerned about? Or what, you know, is it, presumably, I mean, like, they can presumably get any cancer, but are there things that people are more prone to because of their lifestyle? 

Wan-Ley: Yeah so, you’re thinking about people that often have substance dependence and so they’ll be smoking a lot, in the case I’m going to speak about the patient had crack cocaine problems, as well as smoking a lot of cigarettes, and so you’re thinking about lung cancers immediately. Then you’re thinking about people that have really poor diets and are dependent on kind of going to day centres and food banks, where they tend to give high calorie meals to last them through the day, but they’re not the kind of most nutritious and healthiest of meals. And so we think about things like bowel cancers that can happen, but yeah, any cancers really they’re at risk of. 

Rebecca: Can I talk about the case? 

Wan-Ley: Sure. 

Rebecca: Because it’ll be good actually, because I think there’ll be a lot of… Because the other question I want to ask, which we can bank – whose responsibility is it? That’s the question I was going to ask to Sarah, so if you do have some abnormal blood results and you’re trying to get a hold of them and what happens next? But we can talk about that after. I just… 

Wan-Ley: To answer that, I think it’s everyone’s responsibility. So, anyone that comes across it, and, so if I saw those results, I’d try and make sure that everyone knew that they were abnormal, so we have a multidisciplinary team meeting, which involves kind of council, rough sleeper teams, the drugs and alcohol team, the mental health teams, they all come together, and we put the word out that we’re concerned about this, and then they’ll kind of seek in their networks, and if it comes up, they bring it to the next MDT, and we run that every week, so it’s really good for the patients. 

Sarah: You see our homeless patients, because we haven’t got the same service running, it is much more difficult.  

Rebecca: Okay, so the case… 

Wan-Ley: So the case… So the case I’ve got that I’ve brought to the table is a gentleman named Robert, who’s 55 years old and he’d been rough sleeping with a really long history of cigarette smoking, crack cocaine, and heroin use, and he presented with an 18 month history of haemoptysis, or coughing up blood. So I’d met him a few times, and at this presentation he said that he’d been coughing up blood for 18 months or so, and he said, I knew it wasn’t cancer. I’ve had clots before and it’s TB, because he caught TB when he was homeless, and he had scarring on his lungs. So I looked through his notes on Graphnet, we’ve got this joined up computer system that looks at all the hospital records as well, and in our GP records. And he had been to the hospital, and it had shown that two months ago, he’d been in coughing up blood and they’d done a CT-PA, to rule out a blood clot. And they’d said that there was no blood clot and there was a stable appearance of an opacity they found in his left upper lobe. So he was meant to have a follow up scan, but because he’d had that one for the PE, he said that he didn’t need it, and he didn’t go to it, and he was just adamant that he needed antibiotics. So, at that moment in time, the story kind of seemed feasible, so I got him to do a sputum sample, and I booked a review for him at the end of the week, and then the sputum sample did show that he had an infection, so I gave him antibiotics. And that’s when he kind of disappeared off the scene, like, Sarah, you were talking about. He moved accommodation and then I just received the DNA letters that he had for the respiratory clinic appointments and about six weeks had passed from his initial appointment and we were a bit concerned so we brought him up at our MDT meeting, and there they spoke about him and found out where he was living at the time and we managed to make contact with him and at that point he was saying that he was much the same but he’d lost a bit of weight as well and he was still coughing up blood copious amounts of blood. So I brought him into an appointment and I asked if I could examine him and we spoke about things, and, as he took off his clothes, he was wearing lots and lots of layers of clothes, which kind of hid what his true weight was doing, and when he got down to just his bare skin, he was really quite kind of emaciated and cachectic, and so I was quite worried at that point, and I weighed him again, and he’d already lost six kilos from his last record that we had, so that alongside the coughing up of blood, I had to say quite firmly to him that we needed to get him into hospital and really get some scans sorted out for him. He was quite doubtful. He thought about, kind of, conspiracy theories to kill off people at the bottom of society. That’s what he thought about. But having developed a relationship with him, he decided that he trusted me, and he felt that even though it would be a waste of everyone’s time, he’d go along for the scan, and so I managed to speak to his respiratory consultant, explain his situation to him, and he was really good, and he made arrangements for him to be seen, and he had the scan, which showed a suspicious area, so they organised a PET scan, and it did later find that he did have a cancer on board. 

Sarah: Seems really important, doesn’t it, in these patients, particularly if you’re referring them, and if, and if you haven’t got quite the same setup that you’ve got where you’ve got so many people that you can, that you know to call on to get things, that you put as much information in the referral letter of the different ways that you think the patient can be contacted because, you know, we have some patients whose letters come to our practice, but they might not come and pick them up. Phone numbers change very frequently because I think the phones are… they get broken, they get stolen. 

Wan-Ley: Get sold. 

Sarah: Yeah, exactly. And so you’re stuck with that. So I think that having a variety of ways. And then I think that, you know, I love a bit of safety netting, but I think it’s what these sorts of patients you really need to make sure that somebody is tracking within the practice and every practice has a facility to do this, that they’ve, that they’ve had the tests done that you want them to do, that they’ve gone to their appointment and that people are ready at the desk to, if they come in to get the prescription to say, yeah while you’re here, I know that, you know Dr. Taylor wanted you to go… yeah… 

Wan-Ley: Absolutely. Yeah. Well, I mean, the whole point of this, this, this population kind of goes under the radar because people aren’t aware of them. But I often think of it that we have patients that are hard of hearing and there’s flags in the notes that they need adjustments made for them, use the minicom or speak with a sign language tutor. I think people experiencing homelessness should have a flag in the notes to say that they need adjustments made, they need time made for them, and you need to be more intensely following them up like you say and, following up their case because otherwise they get lost very easily. 

Sarah: Yeah. 

Rebecca: I mean, you mentioned that you spoke to the respiratory consultant and made, made him or her aware. What other things can we do with lots of different patients? I mean, in the patients I look after, we don’t have so much of a problem with homelessness, but we have a lot of patients with mental health problems who may need a early appointments, late appointments. I had one particular patient I’m thinking of who had real social anxiety and agoraphobia, so we had to almost organise any investigations to be, like, first thing or last thing when there were no other patients there and it had to be in a certain hospital. And, so we all, we all make these adjustments. 

Wan-Ley: Yeah, that’s great. 

Rebecca: So, for caring for this particular population, do you have any pointers? I know we’re going to talk about these because Sarah and I love, love a practical pointer, don’t we? What other things for Robert, could we do? 

Wan-Ley: So, as we were talking about with Sarah, it’s often inviting them with their support workers to come along, so that, if they don’t, take note of everything that’s being said in the consultation, their support workers might kind of pick up some information or pick up on the key things like appointment times and things. Speaking about appointment times, like you say, that’s, that’s really important, I think, and it’s, it’s on an individual basis, but you’ve got to kind of look at what their lifestyle’s like. So if we have, if we look at sex workers, they often work in the evenings and early mornings, so giving them an appointment first thing in the morning, they’re very likely to kind of miss that appointment, and you need to think about that, and maybe give them a later appointment in the afternoon or something. Building really good relationships with patients, not jumping things, jumping onto them to do lots of tests straight away, but actually, I often work to their agenda first of all, to see what their problems are, and offer them that as the main thing that we deal with to show them that I will take their problems seriously, and that’s what’s important to them. And then over the kind of next two or three appointments that we have, that’s when we start to build in my own agenda into things. But yeah, involving, involving, involving kind of other teams when we’re able to is really important. And also being aware that people that do kind of sleep on the streets, they often are subject to a lot of assaults. And they’ve often had head injuries which can affect their ability to kind of process information and make decisions, and you have to take that into account when talking to people and how you present information to them. 

Sarah: And I think you’ve talked before about the problems of spotting blood in, which I always found really interesting… 

Rebecca: Public toilets, yeah. 

Wan-Ley: Yeah, so in public toilets and not all public toilets but in a lot of fast-food outlets they use these ultraviolet blue lights and the aim of it is so that it’s very difficult to find veins, find your blue veins in that light so you wouldn’t shoot up and use drugs within the toilets. It doesn’t stop people, but they just have worse kind of wounds where they kind of stab in. But, if you’re going to ask them whether they’ve kind of passed any blood or whether they’ve coughed up blood, and they’re doing it in one of these rooms when they, when they go to the toilet, they’re not really going to see whether there’s blood or not, the poo’s just going to look kind of dark, blacky kind of brown. So, even asking them for black poos, it’s, it’s, it’s not a good light for them. But, if they don’t have their own homes where they can control their own lighting, they’re subject to kind of go to the toilet where they’re able to without feeling that they’re going to be stigmatised. So, they often do choose these fast-food outlets. 

Sarah: And you think about the FIT test, Rebecca, which is obviously one of my favourite tests. How do you… Where do you get your mushroom container or your strawberry carton from if you’re homeless, to put your toilet paper and then do your FIT test? You know, those sorts of tests are quite difficult to do, aren’t they? 

Wan-Ley: That’s one of the things that we often have to chase up with patients because we need that in order to kind of complete the referral. I mean, it’s not absolute. If we’re really concerned, we can refer them through, but often if it’s a suspicion and we need that test, it might be actually at the GP’s toilet that we just kind of give them the advice, just say just do it or come into the toilet here and we can help advise you at that point. 

Rebecca: Something that we’ve talked about over the podcast is the importance of examination and you mentioned you have a longer appointment which is something that we may need to take into account with certain patients and give double, triple appointments. You saying that you… Taking the clothes off Robert and seeing he’s wearing lots and lots of layers and we’ve talked about the importance of weighing, haven’t we, and they’re talking about the notches on the, on the belt and the braces and the, the clothes sizes for women because actually if you say, with any patient, have you lost any weight? Oh, no, I don’t think so, doctor. I’ve been the same weight since I was 20. And then you ask that next question saying, have you needed to tighten your belt a little bit more? And they said, Oh, actually I have, and actually weighing them and then seeing them again in a month. And I would not almost consider the wearing lots of clothes as, as another sign. So again, these are just little tips, aren’t they? 

Wan-Ley: Yeah. 

Rebecca: Yeah. I mean, screening is something… She loves a FIT, I love my screening! And… 

Sarah: Sad people, aren’t we?! 

Rebecca: Really sad people! But this must be something that is almost impossible for a lot of homeless and patients of no fixed abode to engage with. 

Wan-Ley: It’s really difficult because your screening letter comes and, and it comes to an address. So if you don’t have an address or you’ve moved address very quickly, you’re not going to get that screening letter. You know, the bowel screening that comes through, it comes through in the post. So what are you going to do? Fortunately there are kind of things set up. So at our service, we have a special kind of project area where we’re looking at things and trying to enhance our screening in our population. So we’ve got quite a small female population, but we ran a, a day where we did a tea day for ladies and, and we brought in tea cakes, had cups of teas, but it was about health education, that was the main thing, and really explaining the importance of it, and also being able to deliver key messages in other languages, and a lot of our asylum seeking refugee population they weren’t aware of the importance of screening, because no one had really explained it to them, and when we gave them, kind of, leaflets to take home, then they were signing up, and they were saying, yeah, we will, we will have this test done, and then often it, it works when one person starts to do it, they tell their friends, oh, do you know what, it wasn’t as bad as, as we thought it might be. And then they go on to have it as well. And so it kind of, it spreads that way. So it’s really helpful. 

Sarah: One of the problems with some of the screening programs, I was quite horrified by some of the stats on the bowel screening, as to how many people with a positive FIT, bearing in mind it’s at a really high level, don’t go on and have the rest of the tests. But that, you know, I’m just thinking, to get somebody who is rough sleeping to do a FIT test is difficult, then to find them to get them to go to the counselling appointment and then to go and have the colonoscopy, that’s an awful lot of hurdles. 

Wan-Ley: Often what, what, we find is that these patients don’t expect to live long lives. You’ve heard the statistics on when they’re going to live up to and they often have this kind of fatalistic view of living and so they think, well, if I’m going to die, I don’t have the best of lives anyway, I’d rather just die with this rather than have to go in and have big operations and anything like that. 

Rebecca: And also it’s the finance of getting, the financial implications of actually getting to the hospital and getting the bus and getting other forms of transport as well. 

Wan-Ley: They often walk everywhere. 

Rebecca: Have you got another case? 

Wan-Ley: I do have another case. 

Rebecca: Can you tell us about it? 

Wan-Ley: So this case is about Martin. So Martin’s a 66 year old Polish gentleman who found himself in the care of the Salford Rough Sleeper Initiative team due to homelessness and a lot of other health issues, which included pre-diabetes, alcohol dependence, gallstones and fatty liver, but his struggles were really exacerbated by his consumption of about a litre of vodka every day and a hesitancy to engage with his community alcohol services. So some colleagues raised some concerns about urinary incontinence that he’d mentioned and he was booked an appointment with the GP to speak about this, but he didn’t really seem keen to engage and just declined any investigations or examinations. So we discussed them at our multidisciplinary team meeting that we hold, and it was identified that our nurse associate, Sarah, would be the best person to spend some time doing what we call pre-engagement work, and that really involves building a good relationship with someone who has a deep mistrust of services by calling them up, it’s almost kind of like annoying them, and checking in with them, explaining to them that you’ll keep calling and keep calling and calling, and despite his initial reluctance to share, he eventually confided in Sarah that he just had this apathy towards his declining health. And that actually spurred Sarah on to kind of take even more proactive steps, so recognising the importance of regular screening, she discussed the possibility of getting a PSA test with Martin, and with the support of a translator, and after consideration, he agreed to undergo the test, because it was a blood test, and it revealed abnormal blood test results with a PSA level of 8. So he was booked in to see me for a physical exam, which essentially was normal, I did a rectal examination, I couldn’t feel a massive prostate, but he was still referred in with that PSA score for a two week wait to urology. But that’s where the story doesn’t really end because the triage appointment at urology found that he was unsuitable because he was heavily intoxicated and subsequently he missed lots of appointments. So, luckily, the, I found that the, the cancer teams in the hospitals are really open to listening to us. And if we explain that someone’s situation is a bit different, they’ll, they’ll try and make, make adjustments for them. And so we carried on building this relationship with him and with our external partners, and there was a health inequalities lead and a cancer screening improvement lead that helped to get involved as we found an appointment that was more suitable for him and his lifestyle. And there they arranged to have a prostatic biopsy, which showed a Gleason score of seven with an adenocarcinoma. And then he had a retropubic prostatectomy and the final pathology revealed a Gleason score of 8. And he did have some kind of lymph node involvement, but after three months of his surgery, his PSA is now undetectable. So, you know, through building lots of rapport and trust, that was paramount in Martin’s kind of story and his journey, and despite his initial nervousness, the persistence from our team, that persistent engagement, and involving other people like his housing worker were really crucial to help him to make sure he attended kind of appointments. And while he faced lots of hurdles, including refusing to attend certain procedures, the commitment of the urological team to accommodate his fears and rearrange appointments showcased a real collaborative effort to kind of address his concerns. 

Sarah: We had a similar patient who, a female patient, who was in a hostel, who was a heavy drug and alcohol user, who had a breast lump, and the case management team were looking after her, and we were trying so hard to get her to appointments and in, but she kept getting admitted, because she was intoxicated. But they would discharge her before getting her to a breast clinic and in the end, I said when next time she’s doing ring the acute oncology nurses, get them to ring the acute oncology nurses in the hospital and maybe one of them will then go and see her and get her into the system and get things sorted. But it’s, it’s, it’s sort of thinking different ways round how to get, because we all knew she needed an assessment. They weren’t discharging her, but she just, we couldn’t get her there. Every, because every time she’d say, you know, on a Thursday, she’d say, Yeah, I’ll go to the appointment tomorrow. Somebody’d turn up, they’d turn up, you know, the appointment would be at midday, she’d be drunk or high and couldn’t get her there. So… 

Wan-Ley: Yeah, those little things that you did are the amazing things that kind of really change a whole person’s story and the journey of kind of what the outcome can be. So, that’s brilliant. 

Rebecca: Yeah. What I’m… listening to you both, because as you know, the patient cohort that I look after is patients who are very involved with their own health on the whole. There’s obviously exceptions, but, and so the idea of somebody not wanting to go to appointments is, is something that I’m, I’m really… 

Sarah: Ooh! 

Rebecca: It’s quite amazing, really, and I think you said something about a lot of homelessness, rough sleeping, sleepers are fatalistic, as in, if it’s my time, and I’m not going to actually spend my time going to appointments and things, but going the extra mile, and using the right person to talk and spend time, and using secondary… Secondary care, primary care, allied health professionals, the, the wider MDT is something that I’m really picking up on and, and those patients that are the exceptions in my cohort actually, going that extra mile and… 

Sarah: But it isn’t just the, it’s I think it’s awareness amongst all the staff as well though, isn’t it, within your surgery, so our receptionists know all of, most of our, certainly the rough sleeping patients, they know who they are because they’re in quite frequently asking about prescriptions, and we, you know, just awareness amongst the practice, all the practice staff, not necessarily specialist people, I think the idea that all your receptionists understand the issues homeless people might have in getting appointments, doing tests, all of that sort of thing is probably quite important too. 

Wan-Ley: I mean we’re looking in our practice to get our front of house staff trained in trauma informed practice so that they really kind of can understand that when people come and present quite aggressively, perhaps sometimes, that it’s not that they’re being aggressive at them, and not to take it personally, but actually there’s lots going on in their lives and talk about, kind of, and teach them about all the things that can, kind of, go wrong in people’s lives, which can kind of affect them and create the attitudes that they have.  

Rebecca: Well I say that to my receptionist all the time because if somebody is quite aggressive or quite angry on the phone, and, and I have a lot of sympathy, particularly for the receptionist, they’re front of house, it’s, it’s often, I say it’s because they’re in pain, they’re, you know, they’re anxious, they’re depressed. There’s, there’s something going on behind it. And, and if you’re a bit softer and try to understand that and not to argue back to them. So I think this is really important work throughout. I just wanted to just ask you about those patients who are in a palliative care setting, or end of life. How does that work if they have no fixed abode? 

Wan-Ley: So, they get prioritised often and they do get given some kind of home if they need to, or some housing, but some patients find that actually their community is on the streets and they, and they actually feel that they feel more at home and more comfortable on the streets, so they prefer to kind of stay on the streets, but then people get very concerned about kind of, prescribing if someone’s like still living on the street and things. We’ve got really good links with our, our hospice. And there’s a doctor down in London, Dr. Caroline Shulman, who’s done phenomenal work in leading forwards kind of palliative care for people experiencing homelessness. And so I know that at St Anne’s Hospice, there’s a specialist that kind of helps to coordinate, these, these populations and goes outside and we also kind of have the Macmillan team that kind of are involved as well. And so it can be a really good result for them when there’s someone that’s kind of closely following up their case, I think. 

Sarah: I was just thinking back to the screening that if you’ve got somebody who you’re talking about doing bowel screening, I could imagine you think well actually if I do the bowel screening and it’s positive then I have a bag how do I do all with a bag on the street and you’d think well I might not just bother with the bowel screening in the first place well you know it’d be easier not to. 

Rebecca: Yeah. I think we could carry on talking about this all day, Wan. It’s been fascinating and there are things that I’m definitely going to take away and put into my own practice as well. As usual, we’re going to just be looking at some key clinical points. Should I start? 

Sarah: Yep.  

Rebecca: Okay. So, red flags, which we learn about, are sometimes not as easy to distinguish with this group of patients. But weight loss, any abnormal blood loss, and a cough could be something more significant. And particularly in patients with no fixed abode. So, red flags need to be kept in your mind despite convincing explanations. 

Wan-Ley: Mm-Hmm. 

Sarah: I’m going to add one in that we haven’t got on the list. So tests and referrals might be quite difficult to arrange, so I think safety netting and following up patients is really, really important. 

Wan-Ley: Yeah, definitely. 

Rebecca: With all patients, but particularly with this cohort, always fully examine the patient with their consent. And what you’ve been saying, Wan, is it may take a few appointments to build up trust. 

Sarah: And try to understand that people’s behaviours may be responses to past traumas and that you might need to make reasonable adjustments to accommodate them. 

Rebecca: I think I also just wanted to say, which wasn’t on the list about head injuries as well ’cause that’s something that you mentioned that actually a lot of these patients may have been assaulted and head injuries can lead to difficulties making executive decisions for these patients. So the link to traumatic brain injuries and we need to make sure that that is taken into account. 

Wan-Ley: Yeah, and you produce, or you give them leaflets that might be in easy read format that are simplified a little so that there’s a greater chance that they’ll understand things. 

Rebecca: Thanks again to both of you. That’s it for today. Thank you to my colleague, Dr. Sarah Taylor, and also to Wan. Thank you for being here. We’ll get you on next time. 

Rebecca: Thanks for listening to this podcast from Gateway C. We hope you’re enjoying this series. Please do support this podcast by leaving us a review or rating wherever you get your podcasts. And if you’ve got any topic suggestions for future episodes, we’d love to hear them. Please do include these in your review. If you’ve found this or other episodes interesting and helpful to your practice, please do share it with a friend or colleague. It really does help to spread the word. We’ve got free cancer courses available on the GatewayC website. All referenced studies and guidelines are in our show notes. Thank you again for listening and thank you to our producers, Jo Newsholme from Rethink Audio and Louise Harbord from GatewayC. See you again soon.