Luther Street Surgery

By Amy Moore

                                                            The first portakabin, 1985 (photo credit: Sally Reynolds)

In 2015, Eve Gibb, a nurse at Luther Street Medical Centre, was interviewed for the centre’s thirtieth anniversary. The interview offered insight into the reasons for the centre's establishment. Gibb remarked about its founder, Dr Hilary Allinson:

She saw that homeless people were falling through the net as they had no address and couldn’t register at a regular GP. So, she started caring for people under the umbrella of her practice in Abingdon.[1]

From this quote it is apparent local initiative was one of the main drivers for this provision. The centre opened in 1985, initiated by Dr. Allinson, a local general practitioner, and David Collett, at the time a project worker at Simon House,[2] It was initially housed in a portacabin outside Oxford Night Shelter in Luther Street , which provided emergency overnight accommodation for rough sleepers in Oxford in an old school building, By 1989, it had expanded its services to include assistance in regaining and maintaining accommodation and in 1998 it moved into a purpose-built building on the car park of the Night Shelter. Over the first decade, the number of patients visiting the centre increased rapidly. In 2005, it expanded to provide additional clinics, (including a dental clinic provided by the community dental service), meetings, and training space.

Luther Street is a product of wider and long-standing conversations around healthcare for those with no fixed address. The need to address health and homelessness on a national level was first acknowledged in the 1867 Metropolitan Poor Act. This act established a connection between workhouses for homeless individuals, often referred to as ‘vagrants’, and the necessity for health services. It required London workhouses to have separate hospital facilities, effectively creating Britain's first state hospitals in the UK.[3] Concerns grew about working men's living conditions, and attitudes toward the homeless changed legally. The 1909 Minority Report of the Royal Commission on the Poor Law affirmed society's duty to assist the ‘vagrant’ rather than punishing them.

Despite these advancements, until the Housing Act of 1977, the legislation focused not on an individual’s accommodation status but on ‘people who were poor’.[4] In 2017, the Homelessness Reduction Act established a statutory link between health inequality and homelessness, emphasising the need to address both. This Act required health services to refer individuals for support where there was a risk of homelessness.[5]

This legislation closely aligned with various health initiatives and the movement towards providing care in the community, a focus in the 1980s. This involved closing mental health institutions, which were initially thought to contribute to the rise in homelessness.[6] However, it should be considered alongside the effects of closing large homeless hostels nationwide, although most were in London.⁷

The Rough Sleepers Unit was established in 1999 to address this increase and published ‘Coming in From the Cold’ in December of that year. This document outlined its strategy to reduce street homelessness by two-thirds by April 2002.[7] Local authorities with 10 or more rough sleepers were required to conduct annual counts, while those with 20 or more should conduct counts every six months. By the summer of 1999, rough sleeping had become a significant issue, with over 40 reported cases in Oxford.[8]

In 2003, the Department of Health published a health action plan that highlighted homelessness as a significant health issue. The Rough Sleepers Initiative expanded beyond London in the 2000s but only supported those sleeping on the streets, neglecting the hidden homeless, like those ‘sofa’ surfing with friends or family, especially in Oxford, where they significantly outnumbered rough sleepers. Additionally, central government tasked primary care trusts in the 2000s with identifying five health priorities, with the Luther Street provision addressing four, focusing on health inequalities worsened by homelessness.

Former staff recall that, in the 1980s, individuals accessing the centre had had prior employment and families, which they lost due to growing dependence on alcohol. Between 1997 and 1999, this shifted as a more diverse group of clients emerged, often from backgrounds of extreme poverty and social exclusion, and of having grown up “in care”, with limited educational and work histories and serious substance misuse challenges. The younger patients frequently lacked any support network outside of homelessness; hence, from 1992 to 1993, there was a significant increase in younger clients aged 16-35, with 20% under 25.[9] Throughout the past forty years current and former staff believe that, the proportion of females accessing the service has remained consistent at 10 -11%.

Over the last forty years, minority ethnic groups numbers have been low staff believe could be due to many from minoritised groups accessing the East Oxford Medical Centre in Cowley Road instead. There has, however, been a rise in individuals escaping conflict in other countries who are seeking assistance. This demographic has long been engaged with the service, and it notably includes a higher proportion of asylum seekers and refugees.

In turning to considering the health needs of the homeless in Oxford during the 1990s, while many London hostels shut down, the closure of numerous psychiatric hospitals, such as St John’s Psychiatric Unit in Buckinghamshire (1990-1995) and Littlemore Hospital in Oxford (1996), also worsened homelessness.[10]

By the early 2000s, the impact of these closures was highlighted by research carried out by the centre on dual diagnosis. This research also provided indicators  that over half of the patients were significantly impacted by co-morbidity, with a notable shift from alcohol use to the abuse of class A drugs, especially heroin.[11] This issue was compounded by the fact that many patients under 25 were not served by accommodation services, which typically catered to those over 25.[12] Additionally, the 2000 study on psychiatric conditions highlighted psychosis as the main issue, closely followed by recurrent depression. A notable number were diagnosed with personality disorders.[13]

Another trend identified was that from 1989 to 1996, the percentage of Luther Street patients dealing with alcohol issues decreased from 76% to 56%. However, research highlighted that despite this reduction, the physical needs of anyone with alcohol problems pointed to a small but significant number with neurological disorders such as epilepsy[14]  In contrast, in 1994, research conducted by the centre indicated that by that year, many individuals seeking help were not fully addicted to drugs but were instead engaging in opportunistic and disordered drug use, which included both prescribed medications and crack cocaine. Centre staff feedback corroborated this trend.[15] Associated with this trend in 1992, the centre conducted research into blood-borne viruses and how they could enhance access to treatment. The research checked 2500 patient records, and 100 patients completed a survey, highlighting that there was an increasing number coming forward to report injecting drug use and that there were associated high levels of risk-taking behaviour. [16] The report also highlighted that there was a significant awareness of HIV amongst those filling in the survey, 41% had been tested with report. Despite this progress 42% reported that they had not changed their behaviour, This may have been due to a ‘fatalistic’ attitude towards their health, as suggested by the report, although there was a reasonable level of concern.[17] Therefore, in 1995, a needle exchange was established, which was integral to the open-access provision and was perceived as a crucial factor in promoting health and preventing these diseases among this population. 

Additionally, the centre conducted a study on incidents of Hepatitis B, which helped to reinforce the immunisation programme introduced in 1992. By 1996, 32% of patients had been enrolled in the programme, and by 1999, the success rate for immunisation against Hepatitis B had reached 91%. However, there was growing concern regarding Hepatitis C. Feedback from interviews with current and former staff indicated that Hepatitis C had been prevalent but had diminished after 2015 due to improvements in medication. This was attributed to the combination of older antiviral medications, often including Interferon, which were then combined with newer antivirals that are more effective and cause fewer side effects. This combination, however, remained reliant on the type of Hepatitis C that a patient had.

Further to these findings a 1997 report marked the first acknowledgement of a significant group of individuals with drug problems who lacked regular agency contact. This translated as highlighted by previous staff members' feedback that the pattern of drug use had evolved, with a typical history by 2000, which was reinforced by research, as follows:

• Experimenting with alcohol and cannabis at ages 14-16.
• Transitioning to amphetamines or, less frequently, cocaine—now possibly coke or crack—and other stimulant party drugs at ages 17-19.
• Introduction to oral heroin use at ages 19-20, evolving to injecting drug use a year or two later.
• Beginning to witness a significant change in heroin misuse as it had begun on some occasions begun at 13. [18]

Furthermore, it is recognised nationally that ill health is exacerbated when someone is homeless, and in 2000, Luther Street conducted a survey regarding the physical health needs of its patients.[19] In examining the data, the most prominent physical health need was respiratory, primarily asthma, with one case of tuberculosis. Another significant need pertained to muscular issues, chiefly relating to a history of chronic pain due to trauma, chronic back pain, and arthritis attributed to lifestyle factors.[20]

Moving on to consider the relationship with the University of Oxford, in answering the question about how educational time at the Practice provided to university students added value, conversations with the centre’s medical education practitioner show that specific students, historically, have been invaluable in supporting the evaluation and development of the Personality Disorder Positive Outcomes Programme.  As the medical education practitioner observed ‘this has been the boost for us to take the project further ourselves’. Moreover, he mentioned that having student placements helped with developing ideas and teaching strategies around homelessness, motivational interviewing, addiction and personality disorder.  Hence, he concluded ‘having day placement students certainly contributed to the development of the wider homelessness and healthcare training programme’. In 2009, this included developing a pathway still apparent within the centre.

This highlights the added value for the university that this type of placement provides students, with insight into how to offer consultations to individuals with complex needs in a safe environment. Additionally, placements have helped students understand the world of homelessness and its complexity in a way they wouldn’t otherwise have had much exposure to but will see many of its consequences firsthand once they are qualified. A tangible outcome has been that some students have come back to work for the centre (for example, GPs and GP locums).

Finally, the practitioner offered the following.

I think there is always a role for students to see how patients with complex needs and homelessness require individualised care and help them ‘get’ why generalist skills, communication skills, treatment planning, and multidisciplinary teamwork are so vital. Through placements, students also need to manage their own emotional responses and preconceptions. All of these skills are useful in all aspects of healthcare.

In conclusion, national policy and legislation have provided a framework for best practice which the centre was already undertaking. While policy might have had some influence, it is apparent that any measures were initiated locally. Hence, the founding of the centre was driven by observations from its founders, Dr Hilary Allison and David Collett who became Director of Oxford Homelessness Pathways, who recognised a gap in healthcare access for the homeless population in Oxford and aimed to initiate change.

I would like to take this opportunity to thank all the staff both current and former for their willingness to take time to meet with me and provide valuable and interesting insights into health and homelessness in Oxford. 

Appendix 1

Definitions

Statutory homelessness refers to individuals who have applied to a local authority housing department for housing on the grounds of ‘priority need’ under the homelessness legislation.

Rough sleepers are individuals who are homeless and sleeping on the streets or in places not meant for habitation, such as doorways, parks, or abandoned buildings.

Sofa surfing is a form of homelessness where people have no permanent place to live and rely on staying with different people for short periods, often on their couches or floors.

Hidden homelessness refers to individuals experiencing homelessness who are not visible on the streets or in official statistics, often living in insecure or unstable housing situations like sofa surfing, squatting, or in unsuitable accommodations, and therefore are not captured in standard homelessness counts.  

                                                          Appendix 2

Timeline summary

1976: Occasional GP surgery was being run at a local shelter on Mill Street near the railway station and then it was moved to north Oxford  

1980: Two surgeries one at in the former Oxford Middle School, on Luther Street  and one at a local hostel each week Simon House in Paradise Street.

1982: Four surgeries per week were held in the Salvation Army Citadel in Castle Street Oxford

1985: Moved into a portacabin, which was bought with money from a legacy left to Dr Hilary Allinson by one of her patients in Abingdon. Oxford Homeless Medical Fund was established with this legacy and became the charity responsible for providing premises and support for non-NHS work for Luther Street patients.

1993: Launched the ‘Building for the Future’ appeal to fund the construction of a new building. This led to charitable contributions, including those from university colleges and individual donors. Eventually, this enabled the funding of the current building.

1993- 1994: The trust raises funds for non-NHS work

Oxford Homeless Medical Fund received funds from the Oxford University Homeless Action group

Grant funding awarded from the social services and health authority

Received numerous donations for the building

1999: Moved into the current building and started offering an acupuncture service

2005: Expanded current building with 2 new nurses’ rooms. This allowed room for a Substance misuse support worker.

Old nurses’ room converted into a dental surgery, community dental services started providing weekly clinics.

Substance misuse team begin running in-house methadone clinics

2009: Mental health homelessness practitioner who worked with street services employed