16. FURTHER READING - ISSUES AND TRENDS

Following an extensive process, spanning nearly two years, the Salvation Army Crisis Services was funded to establish and operate a primary health service in St Kilda in accordance with guidelines set out by the Victorian Department of Human Services. On 1 September 2004, Access Health was officially opened in a large building adjacent to Crisis Services and the primary NSP. In this paper, we seek to provide an insight into the initial establishment phase of a primary care facility designed to meet the health needs of a particularly vulnerable population. It outlines early trends in client need and the service response developed to meet these needs. It also touches upon the relationships that service management has pursued, the structure of the service, and the processes that have been put in place to address (the relatively few) teething problems that have arisen in the facility's first months of operation. In doing so, it provides insight of relevance to all practitioners who encounter the issues that marginalised and vulnerable clients with complex needs often bring.

Street-based IDUs experience many of the same health conditions as the general population. However they are at a disadvantage in respect of frequency, severity, and co-morbidity given the obvious impact on an individual's health of problematic drug use and the environment in which it occurs (e.g. Rowe 2003; Maher & Dixon 1999). The lack of financial security and the absence of secure housing mean that street-based IDUs suffer disproportionately high rates of chronically poor health (Babidge 1999; Darnton-Hill & Ash 1998; Hodder et al. 1998). Further, without some sense of stability and support to counter these factors, there are limits to improvements in an individual's health.

Despite high levels of need, mainstream health services often fail to provide care that is appropriate for street-based IDUs. The combined need to make (and keep) an appointment, for a Medicare card and/or money, and the reality of prolonged waiting times, is an obstacle to vulnerable clients, particularly those who are transient or in need of immediate care (Rowe 2003). Often health is not considered a priority in a chaotic life where survival takes precedence. Indeed, preventative health care and management of chronic illness is often overlooked (McDonald 2002).

Consequently, there is a need for services to be equipped to respond at the moment help is sought. If they are not, then relatively minor ailments may deteriorate to a point at which emergency treatment is required (McDonald 2002). Additionally, the health response that many mainstream services provide may be inflexible and, thus, inappropriate in the context of a client's complex, multiple and interconnected needs (Penrose-Hall et al. 2000). Discrimination, judgmental attitudes and lack of understanding (perceived or otherwise) only further contribute to limited contact with the mainstream health system (Abouyanni et al. 2000; Butt 1992).

In the initial months of operation, many homeless and street-based individuals were attracted to Access Health by the availability of food and coffee making facilities. Access to showers (and the free provision of basic toiletries including soap, shampoo and shaving equipment) also attracted those with limited access to the facilities needed to maintain personal hygiene. Many clients initially came into the service purely to use these services. Continued contact with duty workers ultimately led to engagement and the development of a relationship with the service. This stresses the importance of duty workers who are non-judgmental and possess the skills required to engage and manage complex clients with often challenging behaviours. A number of the more vulnerable clients, initially attracted by the 'drop-in' component of Access Health, have been made to feel sufficiently at ease by duty workers to access the facility's clinical staff. Recruitment of ably equipped 'front of house' staff cannot be overstated when seeking to engage marginalised clients in need of health care.

After nearly six months of operation, the decision was made, in early February, to restrict access to food/coffee making facilities. This decision was taken for a number of reasons. Over the six months, regular clients had been made to feel welcome to a new service and the reticence of particularly marginalised individuals had been overcome through a gradual process of engagement. However, and perhaps more importantly, Access Health risked losing it's focus as a health service and becoming known as a 'drop-in' centre. Further, the issue of prioritising resources was identified. The greater the amount of money spent on food ultimately means less money is available for the provision of material aid such as pharmacy vouchers.

At the same time, Access Health staff acknowledge that (poor) nutrition and hygiene are two of the most pressing health issues they confront. Showers remain available to all clients on a drop in basis. Similarly, food is available. However, it is distributed on the basis of nutritional need as assessed by clinical staff and not as an emergency relief response. Further, a drop in lunch is available to all clients one day a week as a continued means of engagement. Fresh fruit and drinking fountains are provided in the waiting room. Certainly, the decision to restrict access to food was a difficult one. But there are valuable lessons to be learnt regarding service identity and the prioritisation of resources. Further, the number of clients registered at the service continued to grow following this decision, suggesting that it has not affected attendance.

In January 2005, the clinical management software program Pracsoft was installed. In addition to clinical information, Pracsoft records the age and gender of clients 'registered' at Access Health. Registration is not a 'condition' for using the services available at Access Health. Some clients may be reluctant to disclose personal information for a variety of reasons and, consequently, remain unregistered. They may access the service in an informal capacity (e.g. to use showers and toilets). However, clients must be registered when a clinical intervention occurs. In this first month of its operation, 183 clients were registered on Pracsoft. By the end of February, 305 clients were registered and at the end of the first quarter of 2005, there were 383 clients on the Pracsoft database. The breakdown of the age and gender of clients is provided in Table 1 below.

Table 1: Demographics by age and gender (January-March 2005)

Female: 37.6% Male: 62.4%

Men have consistently comprised the greater proportion of Access Health clients, accounting for slightly more than 60% of those using the service. This has led to some gender-based issues.

Indeed, despite extensive research and feasibility studies and the lengthy negotiations that preceded the opening of Access Health, it would have been naïve to expect the facility to operate without encountering some teething problems. Any service dealing with complex issues and vulnerable clients must be structured in a way that allows modification of practice as issues arise. One such issue has been perceived male 'ownership' of common client-based areas (e.g. the waiting room (equipped with television and chairs)) and the front yard area (with tables and chairs). Many of Access Health's female clients have had negative, and often violent, relationships with men. A proportion are street sex workers who have experienced significant gender related power abuses in both their private and public domains. Consequently, some women may be understandably reluctant to wait in an area in which men appear to dominate. A number of women have noted the intimidating nature of common areas:

The drop in group [for lunch on Wednesdays] started to be a bit like that. I thought, as soon as something good starts it's like all these guys come and push in, everyone is going to get a meal but they'll just push in, like, you've got to wait in line. Some of them are okay and some of them are no good (Female, aged 31). ^[???]

This has become less of an issue since unlimited food and coffee was discontinued. Initially, many older, homeless, alcoholic affected men would use the facility for respite from the streets. Many of these men now attend Sacred Heart Mission a short walk down Grey Street where coffee, breakfast and a drop in space is offered. Staff have also sought to address concerns regarding the weekly drop-in session. The presence of two skilled, female staff ensures a better gender balance, a feeling of security for vulnerable women and an informal monitoring situation, with the capacity for intervention when needed. Furthermore, in the months of April and May, the number of female clients has increased at a faster rate than male clients, suggesting the women are comfortable with the structure and service model offered at Access Health.

The ability to survey and address such issues as they arise is important. For this reason, Access Health incorporates an evaluation component, in the form of an on-site researcher, to monitor the facility's operation during its developmental stages. The evaluator/researcher assists staff by identifying areas in which delivery of services may be improved or modified. This is done by gathering information about client outcomes and client satisfaction with the services offered by Access Health through interviews (with clients and staff), surveys and collation of electronic data. In addition to providing for the continued assessment of the efficacy of the service model, this allows data to be provided to funding bodies at regular intervals. Both of these outcomes will contribute to the long-term sustainability of Access Health as a primary health facility.

Finally, it is essential to note the challenges and rewards (to both the Salvation Army Crisis services and Access Health ) of establishing a health service within a welfare agency. Both parties have needed, and worked, to gain a thorough understanding of the philosophies and models with in which the other functions. This is one of the few occasions where the two sectors are not functioning in silos but are (becoming) integrated and enriched. Most importantly, however, those who most benefit are the clients who have access to increased service capacity as a result of the expansion of the 'one-stop-shop concept'. ^[???]

Access Health has only been operational for nine months and unexpected issues may still arise. However, the feasibility studies and research process that preceded this operation has doubtless minimised these to a considerable degree. This and the willingness (and ability) to respond to further issues as they arise are two of the most important aspects that allow the service to function to the degree that client numbers continue to grow. Perhaps more important are the principles according to which the service functions. Namely, that all people are entitled to quality, responsive health care that meets their unique and, at times multifaceted needs. For marginalised individuals and populations, (such as street-based IDUs, street sex workers and people experiencing homelessness), these needs include, not least, a lower health status than other members of the community. Recognition of this fact and the concurrent building of primary health care partnerships has enabled Access Health to go some way to addressing these needs while winning the respect of clients who, to many in the health and welfare sector, are seen as too challenging to deal with:

I would like to acknowledge Ms Sue White the manager of Access Health for comments and assistance in the drafting of this report and the staff and clients of Access Health for their cooperation. Acknowledgement should also go to the Salvation Army Crisis Services for pursuing the best service possible in the interests of their clientele. Finally, I would like to thank the two referees for their constructive criticisms.

Abouyanni, G., Stevens, L.J., Harris, M.F., Wickes, W.A. (2000) 'GP attitudes to managing drug and alcohol dependent patients: A reluctant role' Drug & Alcohol Review 19(2), 165-170.

Babidge, N. (1998) 'Mortality among homeless mentally-ill in Sydney - a ten year follow up. [Unpublished dissertation]

Butt, L. 1992, 'Lighting the lamp' Connexions, July-August, 2-12.

Darnton-Hill, I., Ash, S. (1998) 'Dietary and alcohol intake patterns of a sample of homeless men in Sydney' Australian Journal of Human Nutrition and Dietetics. 1: 397-408.

Department of Human Services (2001) Local Drug Strategies: Directions and Priorities for Funding. Melbourne: Department of Human Services, Drugs Policy & Services Branch.

Hodder, T., Teeson, M., Buhrich, N. (1999) Down and Out in Sydney: Prevalence of mental disorder, disability and health service use among homeless people in inner Sydney. Research Group in Mental Health and Homelessness.

Maher, L., Dixon, D. (1999) 'Policing and public health: law enforcement and harm minimisation in a street-level drug market' British Journal of Criminology 39(4): 488-512.

McDonald, P. (2002) 'From streets to sidewalks: Developments in primary care services for injecting drug users' Australian Journal of Primary Health 8(1): 65-69.

Penrose-Hall, J., Copeland, J., Harris, M. (2000) Shared Care of Illicit Drug Problems by General Practitioners and Primary Health Care Providers: A literature review. Canberra, NDARC.

Rowe, J. (2004) 'From needles and syringes to care and counselling: The need for innovative health care to meet the needs of street-based injecting drug users' Australian Journal of Primary Health, 10(1), 49-55.

Rowe, J. (2003) Who's Using? The health information exchange [St Kilda] and the development of an innovative primary health care response for injecting drug users Melbourne: Salvation Army Crisis Services .