Streets ahead

It was Stevie Smith's death that made Big Issue in the North joint proprietor Anne McNamara 'really fucking angry'.

Stevie Smith only had an abscess on his arm, an easily treatable problem. He was homeless, but he had already taken the first step to getting help, becoming a vendor of the Big Issue street magazine.

But he became the thirteenth Big Issue vendor to die in 1996 in Manchester.

Because he couldn't get the same kind of healthcare the rest of us take for granted. Because the nurse-led clinic he visited couldn't prescribe antibiotics, only bandages. Because he had already walked a mile and a half to get help, and when they told him to see a doctor he didn't want to walk any further.

A week later he was dead. And Anne McNamara was angry, and determined to make sure no more vendors died because they couldn't see a doctor.

Three years later, the result is a health advocacy project in the Big Issue in the North's offices in the centre of Manchester. In the basement of the bright, modern building there is a GP surgery for an hour and a half every day, next door to the computer training room.

Jerry Wilkes, who describes himself as 'happy homeless' says he probably wouldn't have bothered checking out his breathing difficulty if the service wasn't here. 'I just went straight in and got reassured,' he said.

'The last time I saw a doctor before that was nine years ago.'

Like 71 per cent of Big Issue vendors, Mr Wilkes is not registered with a mainstream GP. But here he can talk to project co-ordinator Maggie Harding and link worker Shirley Bill. They assess patients and decide whether they need to see a GP, attend the practice nurses' clinic, go to hospital or be referred to mental health or drugs outreach services.

And it is not restricted to Big Issue vendors. Ms Harding and Ms Bill go out and 'tout for custom' among homeless people and asylum seekers in hostels, B&Bs and on street corners. They work with hospitals to arrange support for homeless people who are being discharged, to ensure that they have somewhere appropriate to go.

So this should be a success story. But things are never that simple. The funding is running out. And as HSJ went to press, the health workers and Big Issue managers were meeting to draw up a battle plan to save the project.

Ms Harding says: 'Homeless people have struggled for years to get access to quality healthcare. To offer that and then remove it would be appalling.'

Jo Purcell, associate director of community care at Manchester health authority, says it is 'struggling' to keep the service going. 'The project has been indicated as a priority in our health improvement programme, but we have no growth money and a£1.5m deficit.'

Ms Purcell is 'putting together' a proposal for a personal medical services pilot scheme to support a part-time salaried GP post at the Big Issue, possibly supplemented by other staff.

Funding is due to end in October. But Ms Purcell says the HA has managed to find£22,000 of 'core funding' to keep the project going until April 2000, as well as£13,000 for 'additional costs' involved in running a branch surgery. Another£30,000, which pays for local GP Dr Gerry O'Shea to spend an hour and half a day at the Big Issue site, will also continue until next April.

But with no growth money for this financial year except for government- ordained projects such as the waiting list initiative, Ms Purcell says: 'It is becoming difficult to identify funding.'

The GP service has been set up as a branch surgery of Dr O'Shea's inner- city practice. Together with his salaried GP colleague Dr Kay Phillips, Dr O'Shea is trying to establish this side of his practice.

But it does not pay well. At any one time there might be between 150 and 200 patients on the list at the health advocacy project. The normal per capita funding for GP lists does not take account of the fact that these are 'difficult' patients, who need a lot of time and support.

One registered patient, an asylum seeker from the Congo, had been tortured. His arm was paralysed and he was suffering muscle wastage. He was referred for physiotherapy and orthopaedic review.

And many patients have multiple health problems, according to a Big Issue survey carried out at the end of last year. Seventy per cent of vendors abuse drugs, most commonly heroin. Confounding the stereotype, 43 per cent of vendors say they do not drink, but 15 per cent say they do have an alcohol problem.

Ms Bill says: 'We see the full range of problems that every other surgery sees, but it is more severe. If you are sleeping rough, ordinary medical problems such as hernias or chronic diseases such as asthma are more debilitating and more difficult to control.'

Add mental health problems, and you can see why many GPs and hospitals find it easier to put up barriers than to treat this group of people.

But Ms McNamara insists the NHS must be made to provide access. 'We pay taxes for a fair and equitable service. And I am not letting the NHS off the hook when it comes to homeless people.'

Running a list for such a mobile population is neither easy, nor cost- effective. Dr O'Shea says: 'We have a policy that we routinely register people, even though that creates a lot of work,' he says. 'At least we get their notes so we can try to tackle their long-term problems.'

The doctors see four or five new patients among the 50 to 60 people seen a week. Ms Harding says: 'The people we deal with have given up asking for help. They have been feeling so lousy for so long they think it is normal. Once they feel better they can start taking charge of their lives.'

The survey established that more than 40 per cent of Big Issue vendors found it difficult to get access to a GP. Ms McNamara says: 'We are working with chaotic people who are not used to keeping appointments.'

Homeless people do not like mainstream GPs' waiting rooms where other patients stare and 'mothers keep their children away from you'. So they tend to wait until there is a crisis and then go to accident and emergency.

The survey found that half the Big Issue vendors had used casualty departments in the past year. Many go with injuries, but 20 per cent visited A&E for 'recurring medical problems'.

As Ms McNamara points out, an avoidable visit to A&E can cost around twice as much as a routine GP appointment. And from the vendor's point of view, A&E is best avoided. Comments in the survey ranged from, 'When they find that you're homeless they haven't got time for you' to, 'They treated me badly because I'm a junkie.'

Ms McNamara says providing good healthcare makes economic and social sense. 'Health is a gateway to other things. If you help a vendor in the short term, you can clean up a wound. But unless you do something else it will come back. We want an integrated approach.'

There is a public health issue, too. Ms Harding points out that the health advocacy project has seen people with typhoid and TB. 'For the health of the community, it is important that they are treated. We can work with people with infectious diseases to ensure care follows them.'

For the future, Ms McNamara is investigating setting up health advocacy projects in Liverpool and Leeds. She says: 'Something like what happened to Stevie wouldn't happen now - he would have that week's grace to see a doctor.

She adds: 'Vendors will still die. They will still overdose and we can't make all of them go to the doctor. But they have started taking responsibility for their health now there is a doctor here.'