Utilisation by homeless people of acute hospital services in London.

OBJECTIVES--To estimate the numbers and distribution of homeless people in London; to quantify the utilisation of acute inpatient services by homeless people in two health authorities; and to predict the total numbers of admissions in homeless people in district health authorities across London. DESIGN--Data were collected from various sources on the distribution of homeless people across London boroughs. All unplanned acute inpatient admissions during November 1990 to relevant hospitals were identified. SETTING--Bloomsbury and Paddington and North Kensington, two former inner London district health authorities. SUBJECTS--Homeless people in London residing in bed and breakfast and private sector leased accommodation, residing in hostels, and of no fixed abode. MAIN OUTCOME MEASURES--Number and cost of acute unplanned admissions in homeless people in two health authorities in November 1990; predicted number of such admissions each year in district health authorities in London. RESULTS--There were at least 60,000 homeless people in London in March 1990. The majority were housed in temporary accommodation (55,412). There were at least 3295 hostel dwellers and 651 people sleeping rough. Homeless people accounted for 105 (8%) of the 1256 acute unbooked admissions in residents of Bloomsbury and Paddington and North Kensington health authorities in November 1990. Considerable variations in the pattern of acute unplanned admissions in homeless people were observed in the two districts with respect to housing status and specialty of admission. The total number of acute unplanned admissions in homeless people across London each year was estimated at 7598, ranging from 38 in Bexley to 1515 in Parkside. CONCLUSIONS--The results have fundamental implications for resource allocation across London. Allocation must take better account of the heterogeneity, uneven distribution, and extra health needs of homeless people.     

Estimating numbers of homeless and homeless mentally ill people in north east Westminster by using capture-recapture analysis.

OBJECTIVES--To use routinely collected data to provide a reliable estimate of the size and psychiatric morbidity of the homeless population of a given geographical area by using capture-recapture analysis. DESIGN--A multiple sample, log-linear capture-recapture method was applied to a defined area of central London during 6 months. The method calculates the total homeless population from the sum of the population actually observed and an estimate of the unobserved population. Data were collected from local agencies used by homeless people. SUBJECTS--Homeless people in north east Westminster residing in bed and breakfast accommodation and hotels or sleeping rough who had contacted statutory or voluntary agencies in the area. RESULTS--2150 contacts by 1640 homeless people were recorded. The estimated unobserved population was 3293, giving a total homeless population for the period of around 5000 (SD 1250). Mental health problems were significantly less prominent in the unobserved compared with the observed population (23% (754) v 40% (627), P < 0.0001). For both groups the prevalence varied greatly with age and sex. CONCLUSIONS--Capture-recapture techniques can overcome problems of ascertainment in estimating populations of homeless and homeless mentally ill people. Prevalences of mental illness derived from surveys that do not correct for ascertainment are likely to be falsely inflated while at the same time underestimating the total size of the homeless mentally ill population. Population estimates derived from capture-recapture techniques may usefully provide a good basis for including homeless populations in capitation calculations for allocating funds within health services.     

Is London overbedded?

OBJECTIVE--To examine whether there are too many hospital beds in London. DESIGN--Analysis of data from the Hospital In-Patient Enquiry, Mental Health Enquiry, health service indicators, and Emergency Bed Service. SETTING--England, London, and inner London. RESULTS--Hospital admission rates for acute plus geriatric services for London residents were very similar to the national values in all age groups. In the special case considered in the Tomlinson report--acute services in inner London--the admission rate was 22% above the value for England. However, the admission rate of inner deprived Londoners was 9% below that of comparable areas outside London. For psychiatry, admission rates in London roughly equalled those in comparable areas. When special health authorities were excluded, in 1990-1 there were 4% more acute plus geriatric beds available per resident in London than in England. Bed provision has been reduced more rapidly in London than nationally. Extrapolating the trend of bed closures forward indicates that beds (all and acute) per resident in London are now at about the national average. Data from the Emergency Bed Service indicate that the pressure on available hospital beds in London has been increasing since 1985. CONCLUSIONS--Data regarding bed provision and utilisation for all specialties by London residents do not provide a case for reducing the total hospital bed stock in London at a rate faster than elsewhere. Bed closures should take account of London''s relatively poorer social and primary health care circumstances, longer hospital waiting lists, poorer provision of residential homes, and evidence from the Emergency Bed Service of increasing pressure on beds. Higher average costs in London, some unavoidable, are forcing hospital beds to be closed at a faster rate in London than nationally.     

Benefits of effective hospital services for elderly people.

An age related hospital service for elderly people was set up in Waltham Forest Health Authority to provide acute medical care when needed. Despite a reduction in the allocation of funds over the years 1982-4 the health authority increased the number of district general hospital beds available for elderly patients and improved home nursing services. The outcomes of the changes made were assessed against the aims of the service by using data from the Hospital Activity Analysis, SH3 returns, government population estimates, and yearly figures collected in our department. It is concluded that introducing an age related service in our health authority has benefited people aged over 65.     

Obstetric outcome in homeless women.

OBJECTIVE--To characterise the pregnant homeless population booking and delivering at St Mary''s Hospital, London, and ascertain whether their obstetric outcome was adversely affected by their homeless condition. DESIGN--Retrospective comparison of demographic characteristics of 185 homeless women booking for delivery with those of housed women booking in the same period and with the population of North West Thames region; comparison of obstetric performance of homeless women with subgroup of the housed population (group matched for age, parity, and ethnic origin). SETTING--Consultant obstetric unit, St Mary''s Hospital, London. SUBJECTS--All women booking between April 1987 and March 1988 who subsequently had a registrable birth. MAIN RESULTS--185 (8%) Of the 2308 women studied were homeless. Compared with the housed population, they had a larger proportion of young women, women of high parity, and Indo-Pakistani women and a smaller proportion of primiparas. Homeless women booked later and had had more previous obstetric problems than housed women. Pregnancy outcome (assessed by birth weight and prematurity rates) was worse than that of both women housed locally and the regional population. Antenatal attendance, complications, intrapartum performance, and perinatal outcome of homeless women did not differ from those in the control group. CONCLUSIONS--This study has been unable to show any significant differences in the outcome of pregnancy in homeless women that can be directly attributed to living in bed and breakfast accommodation, but these women have sociodemographic characteristics and obstetric risk factors that contribute to a poorer outcome in pregnancy than for the general population.     

Health status of the temporarily homeless population and residents of North West Thames region.

OBJECTIVES--To survey the health status of the temporarily homeless population of North West Thames region and make comparisons with regional residents. DESIGN--Direct interview with standardised questionnaires. SETTING--Temporarily homeless people resident in hotels in the London boroughs in the North West Thames region and a random sample of regional residents. SUBJECTS--137 hotels thought to be providing accommodation to homeless people selected at random from a list of 295. 113 (82%) participated in the study, and 319 (61%) of 522 homeless people approached participated. The study was restricted to adults aged 16 and over selected at random. RESULTS--The homeless population was predominantly female (195/319; 61%), young (229 (72%) aged 16-34), and poor, 54% (172/319) receiving income support. 207 subjects (65%) had dependent children aged 16 and under. Rates of acute illness among homeless people (32 cases; 10%) were similar to those reported by regional residents. The prevalence of longstanding limiting illness (108 cases; 34%) was similar to that for regional residents, but the prevalence of mental morbidity was twice that for the region as a whole (145 cases (45%) v 1485 (18%)). Utilisation of general practitioner services, accident and emergency departments, and inpatient admission was much higher by the homeless population than by regional residents. General practitioner registration rates were above 90% for the homeless sample. CONCLUSIONS--Survey data provide empirical evidence about the nature and characteristics of the temporarily homeless population. The high service utilisation recorded may, in part, have resulted from the higher morbidity in this sample of homeless people. The concentration of homeless people into specific locations may suggest that additional funding should be provided to the district which provides care to this group. However, such funding should not necessarily be used for additional acute care but should be used to purchase appropriate services which meet the health needs of this very young, poor and vulnerable group.     

"Homeward bound": a minimal care rehabilitation unit.

A 20 bed minimal care rehabilitation unit was set up by Newham District Health Authority in a small hospital originally scheduled for closure when a new district general hospital was opened. During the first year 114 patients were admitted (throughput 5.7), with a median length of stay of 30 days; in the second year 173 patients were admitted (throughput 8.65) with a median length of stay of 28.5 days. The cost per inpatient day was less than that of an inpatient day at the district''s long stay geriatric unit. Before the unit opened 24% of the acute beds had been occupied for more than six weeks, whereas two years later only 6% of the acute beds were occupied for such a period.     

Relation between bed use,social deprivation,and overall bed availability in acute adult psychiatric units,and alternative residential options: a cross sectional survey,one day census data,and staff interviews.

OBJECTIVES: To examine the relation between bed use, social deprivation, and overall bed availability in acute adult psychiatric units and to explore the range of alternative residential options. DESIGN: Cross sectional survey, combined with one day census data; ratings by and interviews with staff; examination of routine data sources. SETTINGS: Nationally representative sample of acute psychiatric units. SUBJECTS: 2236 patients who were inpatients on census day. MAIN OUTCOME MEASURES: Bed occupancy levels, judged need for continuing inpatient care, reasons preventing discharge, scores on the Health of the Nation outcome scales. RESULTS: Bed occupancy was related to social deprivation and total availability of acute beds (r = 0.66, 95% confidence interval 0.19 to 0.88, F = 8.72, df = 2.23; P = 0.002). However, 27% (603/2215) of current inpatients (61% (90/148) of those with stays of > 6 months) were judged not to need continuing admission. The major reasons preventing discharge were lack of suitable accommodation (37% (176/482) of patients in hospital < 6 months v 36% (31/86) of those in hospital > 6 months); inadequate domiciliary based community support (23% (113) v 9% (8)); and lack of long term rehabilitation places (21% (100) v 47% (40)). Scores on the Health of the Nation outcome scale were generally consistent with these staff judgments. CONCLUSIONS: The shortage of beds in acute psychiatric units is related to both social deprivation and the overall availability of acute beds. Patients currently inappropriately placed on acute admission wards should be relocated into more suitable accommodation, either in hospital or in the community. A range of provisions is required; simply providing more acute beds is not the answer.     

Cognitive function and behavioural status in paediatric heart and heart-lung transplant recipients: the Harefield experience.

OBJECTIVE--To assess the psychological impact of cardiac and cardiopulmonary transplantation on children. DESIGN--Retrospective cross sectional study. SETTING--One British centre performing paediatric heart and heart-lung transplant operations, four cardiac units in London, three London schools, two London health centres, and the dental department of a London children''s hospital. SUBJECTS--65 children who had been given heart or heart-lung transplants and two reference groups of 52 children who had had other types of cardiac surgery and 45 healthy children. MAIN OUTCOME MEASURES--Development, cognition, and behaviour at home and at school as assessed by measures with proved validity and reliability. RESULTS--Developmental and cognitive measures indicated that children given transplants had significantly lower scores on several parameters, particularly in terms of development in children under 4 1/2 years of age. Performance on all tests, however, was within the normal range. There were no significant differences in behavioural ratings between the transplant and reference groups, though problem behaviour at home was more prevalent in the transplant group. CONCLUSIONS--Though cognitive development may be within the normal range, there are adverse psychological effects associated with cardiac and cardiopulmonary transplantation. These data indicate the need for a controlled prospective study in which children and their families are seen before and at regular intervals after transplantation. Interventions should be developed that are tailored to the particular needs of this very specialised group of paediatric patients and their families.     

Exeter Project for Handicapped Children

A project in Exeter has tried to increase the contribution of the paediatric department of a district general hospital to the long-term care, support, and treatment of handicapped children and their families. They include an infant care unit, day units for handicapped children, and holiday projects, and are based on close links with the educational and social services. The availability of such a family support unit may diminish the strain on the families of handicapped children and help them to maintain normal family and social relationships.     

Self referral to accident and emergency department: patients' perceptions.

A study was conducted (a) to assess the number of patients registered with a south London general practice who over 11 weeks referred themselves to an accident and emergency department, (b) to identify the characteristics of those patients, and (c) to determine their perceptions of the services and resources available within their general practices and of the role of accident and emergency departments. Two hundred and thirty four patients referred themselves to a casualty department during the study period, of whom 217 (93%) were interviewed by means of a semistructured questionnaire. Of the 217 patients interviewed, only 15 had tried to contact their general practitioner before attending the casualty department. Eighty nine patients considered that their problem was urgent and required immediate attention and many that they would need an x ray examination. A substantial minority of patients thought that their doctor would not be available. It is concluded that patients'' perceptions of their problems and of access to their doctors are the main determinants of self referral to a casualty department. These findings have important implications for patient education.     

A methodology for projecting hospital bed need: a Michigan case study

Michigan's Department of Community Health (MDCH) is responsible for managing hospitals through the utilization of a Certificate of Need (CON) Commission. Regulation is achieved by limiting the number of beds a hospital can use for inpatient services. MDCH assigns hospitals to service areas and sub areas by use patterns. Hospital beds are then assigned within these Hospital Service Areas and Facility Sub Areas. The determination of the number of hospital beds a facility subarea is authorized to hold, called bed need, is defined in the Michigan Hospital Standards and published by the CON Commission and MDCH. These standards vaguely define a methodology for calculating hospital bed need for a projection year, five years ahead of the base year (defined as the most recent year for which patient data have been published by the Michigan Hospital Association). MDCH approached the authors and requested a reformulation of the process. Here we present a comprehensive guide and associated code as interpreted from the hospital standards with results from the 2011 projection year. Additionally, we discuss methodologies for other states and compare them to Michigan's Bed Need methodology.     

Peripheral paediatric clinics: survey and medical audit.

The work of the paediatric clinics in nine general-practitioner hospitals in country towns in the Bath Health District during 1972 was analysed with respect to the pattern of referrals and methods of management. It is concluded that no child suffered harm from being seen in a clinic without full laboratory and x-ray facilities. Nearly 98% of the consultations were deemed, even with a long period of hindsight, to have been completely satisfactory. The tremendous benefit to the patients and their families of being seen in a hospital near their home is not bought at the cost of a second-rate medical service.     

Primary care development zones.

Most commentators on the Tomlinson report have agreed with its emphasis on improving primary and community care. The three elements of such a strategy are a remedial programme to bring primary care up to national standards, a programme to provide such services to people with non-standard needs such as mobile Londoners, ethnic minorities, and homeless people, and the development of an expanded model of primary care. No one model will be appropriate across all of London. The process should start with an audit of existing resources and services within each community, together with an analysis of needs. From this would develop a local programme with specific plans for investment in premises, staffing, training, and management. New contractual mechanisms may be needed to attract practitioners, improve their premises, secure out of hours services, and provide medical cover for community beds. There should also be incentives for closer working between primary and secondary services. No developments on the scale needed for London have been carried out in primary care within the lifetime of the NHS--but their success will be critical to the calibre of health services for Londoners into the next century.     

General Surgical Pre-admission Clinic

Ninety-nine patients from a non-urgent general surgical waiting list were randomly selected for either direct admission to a hospital bed or review at a preadmission clinic. A considerable reduction in subsequent bed occupancy was shown in the latter group. The findings suggest that more detailed review of patients in the outpatient department would result in the more efficient use of hospital facilities.     

Why are children admitted to hospital?

The criteria for admitting children to hospital for medical care were examined in 399 consecutive, non-planned admissions to the Nottingham Children''s Hospital between October 1975 and January 1976. Sixty-one per cent of the children were referred direct to the casualty department by their parents. Over 20% were admitted primarily for social reasons, and many of the remainder came from homes judged to be at a disadvantage. The hospital medical services for children should be aware of the needs of parents as well as of the needs of sick children in their catchment area.     

Community health services.

The Tomlinson report, with its emphasis on primary and community care, offers great scope to community health services, for long the poor relation of the NHS, and particularly poorly resourced in London. The aim is to create services that break down the barriers between primary, secondary, and tertiary health care and concentrate on providing high quality care tailored to individual patients'' needs. Thus a range of flexible options needs to be developed between acute hospital based care and the standard home care arrangements currently provided by district nurses. Examples, include hospital at home schemes, nursing beds, and rehabilitation beds. Together community and primary care services need to consider weekend coverage, to conduct research, and to become a setting for education. The infrastructure for primary and community care must, however, be put in place before acute facilities are shut.     

The economics of clinical genetics services. III. Cognitive genetics services are not self-supporting.

We investigated the amount of time required to provide, and the charges and reimbursement for, cognitive genetics services in four clinical settings. In a prenatal diagnostic center, a mean of 3 h/couple was required to provide counseling and follow-up services with a mean charge of $30/h and collection of $27/h. Only 49% of personnel costs were covered by income from patient charges. In a genetics clinic in a private specialty hospital, 5.5 and 2.75 h were required to provide cognitive services to each new and follow-up family, respectively. The mean charge for each new family was $25/h and for follow-up families $13/h. The amount collected was less than 25% of that charged. In a pediatric genetics clinic in a large teaching hospital, new families required a mean of 4 h and were charged $28/h; follow-up families also required a mean of 4 h, and were charged $15/h. Only 55% of the amounts charged were collected. Income from patient charges covered only 69% of personnel costs. In a genetics outreach setting, 5 and 4.5 h were required to serve new and follow-up families, respectively. Charges were $25/h and $12/h, and no monies were collected. In all clinic settings, less than one-half of the total service time was that of a physician, and more than one-half of the service time occurred before and after the clinic visit. In no clinic setting were cognitive genetics services self-supporting. Means to improve the financial base of cognitive genetics services include improving collections, increasing charges, developing fee schedules, providing services more efficiently, and seeking state, federal, and foundation support for services.     

Changing patterns of resource allocation in a London teaching district.

The health plans of the Tower Hamlets district management team were studied to determine what effects the report of the Resource Allocation Working Party and the White Paper "Priorities in the Health and Social Services" have had on resource allocation in a teaching district. The study showed that at present acute services are allocated a greater proportion of the district budget than occurs nationally, while geriatrics, mental health, and community services receive proportionately less. In the next three years spending on acute services is expected to decrease, while spending on geriatric facilities and community services will increase. Nevertheless, cuts in acute services will take place mainly through a reduction in the number of beds serving a community function, concentrating all acute services in the teaching hospital. Services to the district might be better maintained by creating a community hospital to meet the needs of patients who would otherwise need to be accommodated in acute beds with unnecessarily expensive support services.