Altogether, nine participants took part in the public involvement events. This included seven (six males, one female) participants in the focus group, and two persons sleeping rough, including one female. The focus group and street engagement lasted approximately 1 hour and 20 minutes, respectively. Key themes from the discussion are presented below, with illustrative quotes presented from the focus group where available. Quotes are not available from individual engagement sessions with persons sleeping rough, as conversations were not recorded and consent to publish their direct quote was not sought, due to practicalities around health literacy and the consent process.
3.2. Perceived Feasibility and Benefits of a Clinical Pharmacy Service
Participants described their experience of visiting their doctor, nurse practitioners, substance misuse nurse and charity workers at the specialist healthcare centre, but not a pharmacist. Participants involved in the discussion mentioned that a clinical pharmacy service based at the specialist homeless healthcare would address many of the barriers homeless persons were facing around access to medicines and healthcare in general.
a) Facilitating Access to Medicines
Participants described that they face a physical inability to visit a pharmacy, due to their multi-morbidities and illnesses and, hence, would often miss the collection of prescriptions. They would value clinical pharmacists’ help in facilitating timely collection of medicine at the specialist healthcare centre, as this was close to their temporary shelters.
‘I’ve got to walk on my heel sometimes, very painful, and if there was a pharmacist down there that’d save me a trip.’
‘Yeah, I’ve missed medication cause I, I couldn’t get, cause I suffer with arthritis so, certain days I, it’s a no go even walking, I can’t walk…’
b) Understanding Prescribed Treatments
Participants described that they often lacked understanding about their prescribed medicines. They would value somebody with expertise in medicine to ‘listen’ and develop a ‘rapport’ with them. One person described that often patients did not understand what was prescribed to them and there was not enough opportunity to query prescribing decisions by the doctors, due to lack of time. A clinical pharmacist based at the specialist primary healthcare centre would facilitate discussion of medicine-related issues. This would aid patient understanding of reasons for prescribing medication and its potential side-effects or interactions, and support better management of health conditions
‘I’ve recently started a new medication cause I was already diagnosed, dual diagnosis, when I was in prison I had an addition diagnosis, I started a new medication but, I’ve not had a chance to speak to anybody about the medication or potential side effects, whatever, whereas if there was a pharmacist there at the time, that would’ve helped a lot … and maybe if the doctor’s being awkward with you or you think that the doctors being unfair, if you’ve got a pharmacist to talk to, they can either back up what the doctor says or back up what you’re saying and then maybe they can go to the doctor. That would be good.’
References were also made to the side effects of the medicines and potential role of pharmacists in preventing and managing the side effects.
‘When they put me on the medication in jail that was an anti-psychotic as well. So, I mean, and if you’re not the right person for that medication it can have really adverse effects. Luckily, I was the right person for it but…’
c) Better Integration across Services
One participant also described a lack of liaison between primary and secondary care and prison services, which often lacked an effective transition of care, particularly with regards to prescribed medicines. A clinical pharmacist would be able to bridge such barriers.
‘I went to hospital once, cause I had an operation, it was stent, stent, yeah, got some but my doctor didn’t know about it until I look a letter to my doctor. He hadn’t had a copy so, he didn’t know what to prescribe me, he wasn’t even aware of the operation …‘. ‘I started heroin in jail cause they stopped my co-codamol. So, I pay for this, and my codeine.’
d) Referral and Liaison with Other Services
Participants also mentioned that pharmacists would be ideal in facilitating their access and engagement with mental health services, as they had an expert understanding of medicines for mental health conditions and the negative impact of a disjointed approach towards the health and well-being of a patient. One of the persons sleeping rough mentioned that many homeless people were often reluctant to be admitted to hospitals, as many hospitals do not offer substance misuse services to inpatients. Clinical pharmacists would hence be effective in their referral process, by identifying and liaising with the ‘right’ hospitals and making sure that patients do not miss their prescribed treatments while in hospital.
e) Minimising Misuse of Prescribed Medicines
Participants described that misuse of prescribed medicines was often common amongst persons experiencing homelessness, as many of them had substance misuse problems. A pharmacist, as an expert in medicines who is based at the specialist centre, would be able to help address substance misuse by diagnoses, advice and referral to substance misuse services
‘… it helps them see if people are abusing their meds, know what I mean, they might see them taking too many straight away or selling on, stuff like that.’
f) Screening, Diagnosis of Health Conditions and Prescribing of Medicines
Participants mentioned that they would trust pharmacists with screening for diseases, diagnostic skills and prescribing medicine and provided examples of their previous experience of pharmacists’ diagnostic skills.
‘Sometimes pharmacists are better at diagnosis than doctors, in my eyes.’
M (age not known)
‘I have one doctor saying I’ve got osteoarthritis, but my pharmacist said no, no, it’s rheumatoid, it is the other one, yeah … and the doctor said, no, it’s rheumatoid arthritis, you know, cause I worked in water, I was a plasterer by trade, so work in water over the years, hands shrank.’
One rough sleeper mentioned that his blood pressure or any form of cardiovascular risk assessment was not done ‘for years’ as nobody had ‘come to’ him and that they were not registered with any general practice. One of the participants of the focus groups currently living in an emergency shelter also said that persons sleeping rough would most benefit from outreach visits.
‘Most people sleeping rough have got multiple problems going on but just don’t (have access to services). They seem to be the sort of people that don’t go to doctor’s appointments, don’t go and see doctors, don’t go and get it taken care of. Cause they’re living their day to day routine on the streets, whatever it is they have to do…they’re developing multiple physical or mental problems, but they (also) never search for any help so, a pharmacist going out to them, they’d be getting the care and attention that they should be getting but, they’re choosing not to for whatever reason. They probably get, they’d probably benefit more from it than anyone.’